NPIMap

Organization Active NPI

Peterson PT LLC

  • Pediatric Sports Medicine Physician
  • Prescott, AZ
National Provider Identifier
1669480968
Registry record updated May 20, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Pediatric Sports Medicine PhysicianTaxonomy code 2080S0010X
License
5079 Issued in AZ
Legal business name
PETERSON PT LLC
Practice address
1320 W Iron Springs Rd
Prescott, AZ 86305-1414
Phone
(928) 771-2977
Fax
(928) 771-2987
NPI assigned
Aug 3, 2006
Organization subpart
No

NPPES NPI Registry

Updated by the provider on May 20, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Brek Lamont PetersonNPI 1518006444
Title
Owner/Physical Therapist
Phone
(928) 771-2977

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 3

Specialty (taxonomy)CodeLicenseStatePrimary
Pediatric Sports Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2080S0010X 5079 AZ Primary
Pediatric Sports Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2080S0010X 5810 AZ
Pediatric Sports Medicine PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2080S0010X 6499 AZ

Addresses

Primary practice location

1320 W Iron Springs Rd
Prescott, AZ 86305-1414

Mailing address

1320 W Iron Springs Rd
Prescott, AZ 86305-1414
Phone (928) 771-2977

Other names 1

  • Peterson Physical Therapy Former legal business name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in AZ

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20040413000254 AZ Part B Supplier - Clinic/Group Practice 1850385824 Receives reassigned benefits from 3 practitioners
Practice locations: Prescott, AZ

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 7

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1154563200000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1716163200000",
    "number": "1669480968",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1320 W IRON SPRINGS RD",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863051414",
            "telephone_number": "928-771-2977",
            "fax_number": "928-771-2987"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1320 W IRON SPRINGS RD",
            "city": "PRESCOTT",
            "state": "AZ",
            "postal_code": "863051414",
            "telephone_number": "928-771-2977",
            "fax_number": "928-771-2987"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PETERSON PT LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2006-08-03",
        "last_updated": "2024-05-20",
        "certification_date": "2024-05-20",
        "status": "A",
        "authorized_official_last_name": "PETERSON",
        "authorized_official_first_name": "BREK",
        "authorized_official_middle_name": "LAMONT",
        "authorized_official_title_or_position": "OWNER/PHYSICAL THERAPIST",
        "authorized_official_telephone_number": "928-771-2977"
    },
    "taxonomies": [
        {
            "code": "2080S0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Sports Medicine",
            "state": "AZ",
            "license": "5079",
            "primary": true
        },
        {
            "code": "2080S0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Sports Medicine",
            "state": "AZ",
            "license": "5810",
            "primary": false
        },
        {
            "code": "2080S0010X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Pediatrics, Sports Medicine",
            "state": "AZ",
            "license": "6499",
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Peterson Physical Therapy",
            "code": "4",
            "type": "Former Legal Business Name"
        }
    ]
}

Other providers in Prescott, AZ

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on May 20, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • Medicare enrollment (CMS PECOS): enrollments, PAC IDs and benefit reassignments.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.