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General NPI Number Information
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NPI Number | 1184015380
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Entity Type | Organization
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Legal Business Name | KENNETH PERCY PETERSON, MD, INC.
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 16850 BEAR VALLEY RD
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City | VICTORVILLE
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State | CA
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Zip | 92395-5794
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Country | US
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Telephone | 760-241-8000
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Fax |
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Provider Business Mailing Address
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Address Line | 12155 MESQUITE ST
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City | OAK HILLS
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State | CA
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Zip | 92344-7903
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Country | US
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Telephone | 805-796-4595
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Fax | 760-662-5711
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KENNETH PERCY PETERSON
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Credential | MD
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Telephone | 805-796-4595
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 282N00000X
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Taxonomy Name | General Acute Care Hospital
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License Number | C50553
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License Number State | CA
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