MEDICARE: C M PETERSON LLC

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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	APN000830 NV	NV

General Provider Information

NPI Number	:	1942472303
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C M PETERSON LLC

Provider Business Mailing Address
First Line	:	1328 FOX ACRES DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0511
Country	:	US
Telephone Number	:	702-332-8353
Fax Number	:	702-921-6828

Provider Business Practice Location Address
First Line	:	1328 FOX ACRES DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89134-0511
Country	:	US
Telephone Number	:	702-332-8353
Fax Number	:	702-921-6828

Authorized Official
Title or Position	:	OWNER
Name	:	CHRISTINE M PETERSON
Credential	:	APN
Telephone Number	:	702-332-8353

Provider Enumeration Date	:	03/26/2008
Last Update Date	:	04/15/2008

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