1760878011 NPI number — CARL PETERSON MBA, ATP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1760878011 NPI number — CARL PETERSON MBA, ATP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PETERSON
Provider First Name:
CARL
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MBA, ATP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1760878011
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 218418
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOUSTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
77218-8418
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
281-492-2799
Provider Business Mailing Address Fax Number:
281-492-7479

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16820 BARKER SPRINGS RD
Provider Second Line Business Practice Location Address:
SUITE E500
Provider Business Practice Location Address City Name:
HOUSTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
77084-5040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
281-492-2799
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/14/2015

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 247200000X , with the licence number:  ATP85795 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: ATP85795 . This is a "RESNA" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".




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