Provider Demographics
NPI:1700928421
Name:MELVIN, BRENT ALAN (ATC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:ALAN
Last Name:MELVIN
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 1:1908 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:NE
Mailing Address - Zip Code:68421-3044
Mailing Address - Country:US
Mailing Address - Phone:402-872-7217
Mailing Address - Fax:
Practice Address - Street 1:600 HOYT ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:NE
Practice Address - Zip Code:68421
Practice Address - Country:US
Practice Address - Phone:402-872-2390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE4002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer