=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679752802
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RANDOLPH E PETERSON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/24/2007
-----------------------------------------------------
Last Update Date | 10/24/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 840 SW 4TH AVENUE
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-2627
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-2899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1460
-----------------------------------------------------
City | ONTARIO
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97914-1066
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 541-889-2899
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | LESLIE PETERSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 541-889-2899
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207X00000X
-----------------------------------------------------
Taxonomy Name | Orthopaedic Surgery Physician
-----------------------------------------------------
License Number | 19969
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------