MEDICARE: BRENDA PECK

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	47031053541	MI

General Provider Information

NPI Number	:	1154704054
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRENDA PECK

Provider Business Mailing Address
First Line	:	18621 BLUE ISLAND CT
Second Line	:
City	:	ROSEVILLE
State	:	MI
Zip	:	48066-2938
Country	:	US
Telephone Number	:	313-243-6891
Fax Number	:

Provider Business Practice Location Address
First Line	:	18621 BLUE ISLAND CT
Second Line	:
City	:	ROSEVILLE
State	:	MI
Zip	:	48066-2938
Country	:	US
Telephone Number	:	313-243-6891
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/09/2015
Last Update Date	:	07/09/2015

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Directions to “ BRENDA PECK ” Practice Location

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