MEDICARE: CHRISTOPHER PETERSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency	400516640605	OH

General Provider Information

NPI Number	:	1417387184
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CHRISTOPHER PETERSON

Provider Business Mailing Address
First Line	:	10618 WOODLAND AVE
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-2436
Country	:	US
Telephone Number	:	216-640-1898
Fax Number	:

Provider Business Practice Location Address
First Line	:	10618 WOODLAND AVE APT A
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44104-2436
Country	:	US
Telephone Number	:	216-640-1898
Fax Number	:

Authorized Official
Title or Position	:	STNA
Name	:	CHRISTOPHER TYRONE PETERSON
Credential	:
Telephone Number	:	216-640-1898

Provider Enumeration Date	:	11/18/2013
Last Update Date	:	11/18/2013

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