MEDICARE: MR. BRENT A PETRE DPT

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	225100000X	Physical Therapist	PT34764	CA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AZ971Z	OTHER	CA	MEDICARE PTAN

General Provider Information

NPI Number	:	1518115369
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRENT A PETRE DPT

Provider Business Mailing Address
First Line	:	4910 DIRECTORS PL
Second Line	:	SUITE 370
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3811
Country	:	US
Telephone Number	:	858-554-0522
Fax Number	:	858-554-0536

Provider Business Practice Location Address
First Line	:	4910 DIRECTORS PL
Second Line	:	SUITE 370
City	:	SAN DIEGO
State	:	CA
Zip	:	92121-3811
Country	:	US
Telephone Number	:	858-554-0522
Fax Number	:	858-554-0536

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

Provider Enumeration Date	:	09/05/2008
Last Update Date	:	09/01/2016

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