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General NPI Number Information
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NPI Number | 1902096738
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Entity Type | Individual
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Provider Name | MARK S PETERS RD
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Gender | Male
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Dates
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Enumeration Date | 07/27/2007
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Last Update Date | 07/27/2007
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Provider Practice Location Address
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Address Line | 211 S 3RD ST
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City | BELLEVILLE
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State | IL
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Zip | 62220-1915
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Country | US
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Telephone | 618-234-2120
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Fax |
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Provider Business Mailing Address
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Address Line | 5435 LIONS DEN SPUR
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City | IMPERIAL
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State | MO
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Zip | 63052-3900
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Country | US
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Telephone | 636-296-0047
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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 | 133V00000X
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Taxonomy Name | Registered Dietitian
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License Number |
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License Number State | IL
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