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General NPI Number Information
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NPI Number | 1184827693
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Entity Type | Individual
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Provider Name | DALE EDMUND PETERSEN JR. CP
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Gender | Male
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Dates
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Enumeration Date | 06/11/2007
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Last Update Date | 03/28/2008
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Provider Practice Location Address
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Address Line | 4299 3RD AVE
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City | MARIANNA
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State | FL
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Zip | 32446-2136
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Country | US
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Telephone | 850-526-0063
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Fax | 850-526-1317
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Provider Business Mailing Address
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Address Line | PO BOX 430
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City | MARIANNA
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State | FL
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Zip | 32447-0430
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Country | US
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Telephone | 850-526-0063
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 224P00000X
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Taxonomy Name | Prosthetist
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License Number | PRO66
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License Number State | FL
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