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Individual

TIM PETERSEN

Active
Sole proprietor
No

Provider details

NPI number
Gender
Man

Contact information

Practice address
32059 N STATE ROUTE 97, FAIRVIEW, IL 61432-9643
(309) 414-2155
Mailing address
32059 N STATE ROUTE 97, FAIRVIEW, IL 61432-9643
(309) 414-2155

Taxonomy

Speciality
Code
Description
License number
State
172A00000X
Driver
Primary
P362-8106-6065
IL

Other

Enumeration date
02/23/2017
Last updated
02/23/2017
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