Provider Demographics
NPI:1225563372
Name:PRENDINGUE, BRIAN (IDC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:PRENDINGUE
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:606 3RD AVE APT 405
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-6841
Mailing Address - Country:US
Mailing Address - Phone:757-805-9394
Mailing Address - Fax:
Practice Address - Street 1:USS SENTRY
Practice Address - Street 2:MCM 3
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09587-1923
Practice Address - Country:US
Practice Address - Phone:757-805-9394
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-26
Last Update Date:2017-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA1710I1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman