Provider Demographics
NPI:1750079547
Name:MAINS, BRENT D
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:D
Last Name:MAINS
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 1:833 E COVENTRY LN
Mailing Address - Street 2:
Mailing Address - City:ALPINE
Mailing Address - State:UT
Mailing Address - Zip Code:84004-1240
Mailing Address - Country:US
Mailing Address - Phone:385-447-7929
Mailing Address - Fax:
Practice Address - Street 1:833 E COVENTRY LN
Practice Address - Street 2:
Practice Address - City:ALPINE
Practice Address - State:UT
Practice Address - Zip Code:84004-1240
Practice Address - Country:US
Practice Address - Phone:385-447-7929
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-28
Last Update Date:2023-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program