Healthcare Provider Details

I. General information

NPI: 1497162408
Provider Name (Legal Business Name): BRIAN PETITE PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2014
Last Update Date: 07/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6880 PERIMETER DR
DUBLIN OH
43016-2520
US

IV. Provider business mailing address

6880 PERIMETER DR
DUBLIN OH
43016-2520
US

V. Phone/Fax

Practice location:
  • Phone: 614-791-0077
  • Fax: 614-791-0011
Mailing address:
  • Phone: 614-791-0077
  • Fax: 614-791-0011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberPTA09564
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: