Provider Demographics
NPI:1609182062
Name:PETRICK, BRENTON A
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:A
Last Name:PETRICK
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 1:13341 COMMONWEALTH ST
Mailing Address - Street 2:
Mailing Address - City:SOUTHGATE
Mailing Address - State:MI
Mailing Address - Zip Code:48195-1287
Mailing Address - Country:US
Mailing Address - Phone:734-624-0964
Mailing Address - Fax:
Practice Address - Street 1:19401 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2277
Practice Address - Country:US
Practice Address - Phone:734-785-7718
Practice Address - Fax:734-287-8221
Is Sole Proprietor?:No
Enumeration Date:2010-08-24
Last Update Date:2010-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant