Provider Demographics
NPI:1114143237
Name:PETRILLI, BRETT JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:JOHN
Last Name:PETRILLI
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11014 SE 192ND ST
Mailing Address - Street 2:
Mailing Address - City:RENTON
Mailing Address - State:WA
Mailing Address - Zip Code:98055-7432
Mailing Address - Country:US
Mailing Address - Phone:253-852-8640
Mailing Address - Fax:253-854-2690
Practice Address - Street 1:11014 SE 192ND ST
Practice Address - Street 2:
Practice Address - City:RENTON
Practice Address - State:WA
Practice Address - Zip Code:98055-7432
Practice Address - Country:US
Practice Address - Phone:253-852-8640
Practice Address - Fax:253-854-2690
Is Sole Proprietor?:No
Enumeration Date:2007-04-17
Last Update Date:2015-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH0002201111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA911498710OtherTAX ID#
WAPE9824OtherREGENCE RIDER #
WA43666OtherDEPT OF L&I
WAG8912328OtherMEDICARE PTAN
WAT02049Medicare UPIN