Provider Demographics
NPI:1699755546
Name:PETERSON, RICKY L (PT)
Entity type:Individual
Prefix:MR
First Name:RICKY
Middle Name:L
Last Name:PETERSON
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 48TH ST
Mailing Address - Street 2:SUITE 120
Mailing Address - City:WEST DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50266-6723
Mailing Address - Country:US
Mailing Address - Phone:515-224-1474
Mailing Address - Fax:515-224-1478
Practice Address - Street 1:1701 48TH STREET
Practice Address - Street 2:SUITE 120
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-6723
Practice Address - Country:US
Practice Address - Phone:515-224-1474
Practice Address - Fax:515-224-1478
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-18
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01473225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0285478Medicaid
IA33194OtherBCBS
IAI9163Medicare PIN