Individual
DALE EDMUND PETERSEN JR.
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CP
Contact information
Practice address
4299 3RD AVE, MARIANNA, FL 32446-2136
(850) 526-0063
(850) 526-1317
Mailing address
PO BOX 430, MARIANNA, FL 32447-0430
(850) 526-0063
Taxonomy
Speciality
Code
Description
License number
State
224P00000X
Prosthetist
Primary
PRO66
FL
Other
Enumeration date
06/11/2007
Last updated
03/28/2008
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