=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891293668
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PETERSEN MEDICAL CORP.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2018
-----------------------------------------------------
Last Update Date | 01/26/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7235 CORAL WAY STE 213
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-846-9303
-----------------------------------------------------
Fax | 305-640-5705
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7235 CORAL WAY STE 213
-----------------------------------------------------
City | MIAMI
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33155-1452
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-846-9303
-----------------------------------------------------
Fax | 305-640-5705
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | KYLE PETERSEN
-----------------------------------------------------
Credential | DO
-----------------------------------------------------
Telephone | 305-846-9303
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0400X
-----------------------------------------------------
Taxonomy Name | Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------