MEDICARE: TY PETERS

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	224Z00000X	Occupational Therapy Assistant	3232	SC

General Provider Information

NPI Number	:	1659704393
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TY PETERS

Provider Business Mailing Address
First Line	:	4269 CREPE MYRTLE CT UNIT E
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-4316
Country	:	US
Telephone Number	:	703-399-6086
Fax Number	:

Provider Business Practice Location Address
First Line	:	4269 CREPE MYRTLE CT UNIT E
Second Line	:
City	:	MURRELLS INLET
State	:	SC
Zip	:	29576-4316
Country	:	US
Telephone Number	:	703-399-6086
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/16/2013
Last Update Date	:	08/16/2013

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