=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629697800
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRENT PATRICK TWIFORD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2020
-----------------------------------------------------
Last Update Date | 12/05/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 400 W MINERAL KING AVE
-----------------------------------------------------
City | VISALIA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93291-6237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 559-901-8659
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3534 5TH AVE APT 422
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92103-5069
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2085R0202X
-----------------------------------------------------
Taxonomy Name | Diagnostic Radiology Physician
-----------------------------------------------------
License Number | 20A23904
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------