Provider Demographics
NPI:1992449680
Name:PETTY, BRENT ERIC (RVT, RDMS)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:ERIC
Last Name:PETTY
Suffix:
Gender:M
Credentials:RVT, RDMS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:530 E QUEEN ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90301-1929
Mailing Address - Country:US
Mailing Address - Phone:310-946-3707
Mailing Address - Fax:
Practice Address - Street 1:530 E QUEEN ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90301-1929
Practice Address - Country:US
Practice Address - Phone:310-946-3707
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-27
Last Update Date:2022-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1463002471V0105X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2471V0105XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistVascular Sonography