Healthcare Provider Details

I. General information

NPI: 1497281406
Provider Name (Legal Business Name): DR. BRENT PICKETT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2017
Last Update Date: 02/17/2022
Certification Date: 02/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 N 500 E
LOGAN UT
84341-2400
US

IV. Provider business mailing address

260 N 750 E
VINEYARD UT
84058-5816
US

V. Phone/Fax

Practice location:
  • Phone: 435-716-2800
  • Fax:
Mailing address:
  • Phone: 435-760-1679
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number12423819-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: