Provider Demographics
NPI:1518421122
Name:PECK, GARRETT
Entity Type:Individual
Prefix:
First Name:GARRETT
Middle Name:
Last Name:PECK
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 1:2971 64TH ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2623
Mailing Address - Country:US
Mailing Address - Phone:415-235-1264
Mailing Address - Fax:
Practice Address - Street 1:2971 64TH ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2623
Practice Address - Country:US
Practice Address - Phone:415-235-1264
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-28
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA996705969Medicaid