Individual
MR. MARK FREDERIC PETERSON I
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Contact information
Practice address
3351 36TH ST, GRAND RAPIDS, MI 49331
(616) 831-5659
Mailing address
2285 CHRISTINE CT SE, GRAND RAPIDS, MI 49546
(616) 831-5659
Taxonomy
Speciality
Code
Description
License number
State
320900000X
Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
Primary
6802071051
MI
Other
Enumeration date
12/24/2007
Last updated
12/24/2007
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