Provider Demographics
NPI:1851761464
Name:BRENT LEAVITT
Entity Type:Organization
Organization Name:BRENT LEAVITT
Other - Org Name:MAXIMUM SECURITY INC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEAVITT
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:208-760-9416
Mailing Address - Street 1:4928 PLEASANT VIEW DR
Mailing Address - Street 2:
Mailing Address - City:CHUBBUCK
Mailing Address - State:ID
Mailing Address - Zip Code:83202-1640
Mailing Address - Country:US
Mailing Address - Phone:208-760-9416
Mailing Address - Fax:
Practice Address - Street 1:4928 PLEASANT VIEW DR
Practice Address - Street 2:
Practice Address - City:CHUBBUCK
Practice Address - State:ID
Practice Address - Zip Code:83202-1640
Practice Address - Country:US
Practice Address - Phone:208-760-9416
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-25
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID282NC0060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC0060XHospitalsGeneral Acute Care HospitalCritical Access