Organization
KENNETH A PETERSON
Active
Organization subpart
No
Provider details
NPI number
Authorized official
DR. KENNETH PETERSON OD (OWNER)
(805) 473-9393
Entity
Organization
Contact information
Practice address
911 OAK PARK BLVD STE 104, PISMO BEACH, CA 93449-3406
(805) 473-9393
Mailing address
911 OAK PARK BLVD STE 104, PISMO BEACH, CA 93449-3406
Taxonomy
Speciality
Code
Description
License number
State
332H00000X
Eyewear Supplier
Primary
CA 9884T
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OP9884
MEDICARE ID
CA
05
—
SD0098840
—
CA
Enumeration date
03/30/2009
Last updated
03/30/2009
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