Healthcare Provider Details

I. General information

NPI: 1295818045
Provider Name (Legal Business Name): BRENCO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

157 F E SELLERS HWY
MONTICELLO MS
39654
US

IV. Provider business mailing address

PO BOX 802
MONTICELLO MS
39654-0802
US

V. Phone/Fax

Practice location:
  • Phone: 601-587-1367
  • Fax: 601-587-0968
Mailing address:
  • Phone: 601-587-1367
  • Fax: 601-587-0968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number
License Number State

VIII. Authorized Official

Name: MRS. OLLIE BRENT
Title or Position: OFFICE MANAGER
Credential:
Phone: 601-587-1367