MEDICARE: BRANDON PETITE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172V00000X	Community Health Worker

General Provider Information

NPI Number	:	1205559622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRANDON PETITE

Provider Business Mailing Address
First Line	:	2600 ARROYO AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1842
Country	:	US
Telephone Number	:	682-336-9799
Fax Number	:

Provider Business Practice Location Address
First Line	:	2600 ARROYO AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75219-1842
Country	:	US
Telephone Number	:	682-336-9799
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/21/2022
Last Update Date	:	09/29/2022

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Directions to “ BRANDON PETITE ” Practice Location

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