Provider Demographics
NPI:1497410906
Name:REARICK, BRENDON
Entity Type:Individual
Prefix:
First Name:BRENDON
Middle Name:
Last Name:REARICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2041 TRAILSIDE DR
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-7306
Mailing Address - Country:US
Mailing Address - Phone:978-502-1977
Mailing Address - Fax:
Practice Address - Street 1:101 W AVENIDA VISTA HERMOSA STE 120
Practice Address - Street 2:
Practice Address - City:SAN CLEMENTE
Practice Address - State:CA
Practice Address - Zip Code:92672-7707
Practice Address - Country:US
Practice Address - Phone:949-891-0328
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-01
Last Update Date:2021-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date: