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General NPI Number Information
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NPI Number | 1407925738
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Entity Type | Organization
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Legal Business Name | PRESCOTT FOOT & ANKLE CLINIC PC
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Dates
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Enumeration Date | 11/08/2006
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Last Update Date | 02/08/2008
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Provider Practice Location Address
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Address Line | 919 12TH PLACE SUITE 10
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City | PRESCOTT
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State | AZ
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Zip | 86305-1433
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Country | US
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Telephone | 928-776-0770
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Fax | 928-776-8991
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Provider Business Mailing Address
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Address Line | 919 12TH PLACE SUITE 10
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City | PRESCOTT
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State | AZ
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Zip | 86305-1433
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Country | US
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Telephone | 928-776-0770
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Fax | 928-776-8991
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Authorized Official
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Title or Position | OWNER
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Name | KENT L PETERSON
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Credential | DPM
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Telephone | 928-776-0770
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | 0261AZ
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License Number State | AZ
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