Healthcare Provider Details

I. General information

NPI: 1821513086
Provider Name (Legal Business Name): BRENTON HEVRIN PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2017
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 E HORIZON RIDGE PKWY STE 180
HENDERSON NV
89002-7937
US

IV. Provider business mailing address

70 E HORIZON RIDGE PKWY STE 180
HENDERSON NV
89002-7937
US

V. Phone/Fax

Practice location:
  • Phone: 702-856-0422
  • Fax: 702-433-0425
Mailing address:
  • Phone: 702-856-0422
  • Fax: 702-433-0425

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberA-1035
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: