Provider Demographics
NPI:1710612155
Name:CLEVENGER, BRENT
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:CLEVENGER
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:PO BOX 933
Mailing Address - Street 2:
Mailing Address - City:SNOWFLAKE
Mailing Address - State:AZ
Mailing Address - Zip Code:85937-0933
Mailing Address - Country:US
Mailing Address - Phone:520-704-0937
Mailing Address - Fax:
Practice Address - Street 1:287 W SPRUCE
Practice Address - Street 2:
Practice Address - City:SNOWFLAKE
Practice Address - State:AZ
Practice Address - Zip Code:85937-8593
Practice Address - Country:US
Practice Address - Phone:520-704-0937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZD01848528347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle