Provider Demographics
NPI:1285416206
Name:MCKECUEN, BRENT JAMISON
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:JAMISON
Last Name:MCKECUEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 DANCES BAY RD
Mailing Address - Street 2:
Mailing Address - City:ELIZABETH CITY
Mailing Address - State:NC
Mailing Address - Zip Code:27909-9172
Mailing Address - Country:US
Mailing Address - Phone:252-339-1922
Mailing Address - Fax:
Practice Address - Street 1:417 S HUGHES BLVD
Practice Address - Street 2:
Practice Address - City:ELIZABETH CITY
Practice Address - State:NC
Practice Address - Zip Code:27909-4526
Practice Address - Country:US
Practice Address - Phone:252-339-1922
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-16
Last Update Date:2024-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC343900000X
3416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)