Basic Information
| Provider Information | |||||||||
| NPI: | 1124161385 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PETERSON | ||||||||
| FirstName: | BRENT | ||||||||
| MiddleName: | ALLEN | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | B.S., B.C.-H.I.S. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 VICTORY DR | ||||||||
| Address2: | |||||||||
| City: | LIBERTY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 640683807 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8163132800 | ||||||||
| FaxNumber: | 8167929819 | ||||||||
| Practice Location | |||||||||
| Address1: | 153 W 151ST ST | ||||||||
| Address2: | 140 | ||||||||
| City: | OLATHE | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660615348 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9137645355 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/15/2007 | ||||||||
| LastUpdateDate: | 07/12/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 1275 | KS | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.