Healthcare Provider Details

I. General information

NPI: 1336476514
Provider Name (Legal Business Name): TREY COLIN PETTY R.T.(R)
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 11/10/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4508 37TH ST
LUBBOCK TX
79414-2615
US

IV. Provider business mailing address

4508 37TH ST
LUBBOCK TX
79414-2615
US

V. Phone/Fax

Practice location:
  • Phone: 806-778-8017
  • Fax:
Mailing address:
  • Phone: 806-778-8017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number23364
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRT 00007061
License Number StateWA
# 3
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberRHF 96247
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License NumberR-3058
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: