Provider Demographics
NPI:1821194697
Name:PICKERING, BRIAN KEITH (ATC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:KEITH
Last Name:PICKERING
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2511 18TH ST S
Mailing Address - Street 2:
Mailing Address - City:MOORHEAD
Mailing Address - State:MN
Mailing Address - Zip Code:56560-4810
Mailing Address - Country:US
Mailing Address - Phone:218-770-4900
Mailing Address - Fax:
Practice Address - Street 1:615 S MILL ST
Practice Address - Street 2:
Practice Address - City:FERGUS FALLS
Practice Address - State:MN
Practice Address - Zip Code:56537-2756
Practice Address - Country:US
Practice Address - Phone:218-739-6889
Practice Address - Fax:218-739-5501
Is Sole Proprietor?:No
Enumeration Date:2006-09-16
Last Update Date:2015-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN16242255A2300X
ND307-062255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer