MEDICARE: PETERSON DORCE

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	247200000X	Other Technician

General Provider Information

NPI Number	:	1952642860
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PETERSON DORCE

Provider Business Mailing Address
First Line	:	4398 SW VERINK ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-7822
Country	:	US
Telephone Number	:	305-330-8101
Fax Number	:

Provider Business Practice Location Address
First Line	:	4398 SW VERINK ST
Second Line	:
City	:	PORT SAINT LUCIE
State	:	FL
Zip	:	34953-7822
Country	:	US
Telephone Number	:	305-330-8101
Fax Number	:

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

Provider Enumeration Date	:	03/04/2013
Last Update Date	:	01/16/2014

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Directions to “ PETERSON DORCE ” Practice Location

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