MEDICARE: PETERKIN & ASSOCIATES, INC.

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	320600000X	Intellectual and/or Developmental Disabilities Residential Treatment Facility

General Provider Information

NPI Number	:	1932413457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PETERKIN & ASSOCIATES, INC.

Provider Business Mailing Address
First Line	:	131 HAY STREET
Second Line	:	SUITE 201
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28301-5649
Country	:	US
Telephone Number	:	910-323-1817
Fax Number	:	910-323-2607

Provider Business Practice Location Address
First Line	:	2692 HARRIS STREET
Second Line	:
City	:	EAST POINT
State	:	GA
Zip	:	30344-2672
Country	:	US
Telephone Number	:	770-595-6705
Fax Number	:	770-421-6003

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	DR. ALICE D. SMITH
Credential	:	ED.D.
Telephone Number	:	910-323-1817

Provider Enumeration Date	:	07/27/2010
Last Update Date	:	07/27/2010

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