Provider Demographics
NPI:1629841119
Name:CARLSON, BRENT CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:CHRISTOPHER
Last Name:CARLSON
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 1:74088 GORGONIO DR
Mailing Address - Street 2:
Mailing Address - City:TWENTYNINE PALMS
Mailing Address - State:CA
Mailing Address - Zip Code:92277-2714
Mailing Address - Country:US
Mailing Address - Phone:619-844-3290
Mailing Address - Fax:
Practice Address - Street 1:60805 29 PALMS HWY
Practice Address - Street 2:
Practice Address - City:JOSHUA TREE
Practice Address - State:CA
Practice Address - Zip Code:92252-5901
Practice Address - Country:US
Practice Address - Phone:760-974-5990
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-06
Last Update Date:2023-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT41132164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse