MEDICARE: MR. RICKY L PETERSON PT

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	225100000X	Physical Therapist	01473	IA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	33194	OTHER	IA	BCBS

General Provider Information

NPI Number	:	1699755546
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. RICKY L PETERSON PT

Provider Business Mailing Address
First Line	:	1701 48TH ST
Second Line	:	SUITE 120
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6723
Country	:	US
Telephone Number	:	515-224-1474
Fax Number	:	515-224-1478

Provider Business Practice Location Address
First Line	:	1701 48TH STREET
Second Line	:	SUITE 120
City	:	WEST DES MOINES
State	:	IA
Zip	:	50266-6723
Country	:	US
Telephone Number	:	515-224-1474
Fax Number	:	515-224-1478

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

Provider Enumeration Date	:	01/18/2006
Last Update Date	:	06/04/2008

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Directions to “ MR. RICKY L PETERSON PT” Practice Location

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