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General NPI Number Information
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NPI Number | 1326392036
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Entity Type | Organization
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Legal Business Name | KEVIN C PETERSON OD PC
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Dates
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Enumeration Date | 11/02/2012
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Last Update Date | 11/02/2012
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Provider Practice Location Address
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Address Line | 1845 LOCKEWAY DR SUITE 401
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City | ALPHARETTA
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State | GA
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Zip | 30004-5936
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Country | US
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Telephone | 770-664-5580
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Fax |
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Provider Business Mailing Address
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Address Line | 1845 LOCKEWAY DR SUITE 401
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City | ALPHARETTA
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State | GA
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Zip | 30004-5936
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | DR. KEVIN C PETERSON
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Credential |
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Telephone | 770-664-5580
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 1697
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License Number State | GA
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