Basic Information
Provider Information | |||||||||
NPI: | 1164900015 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NANKERVILLE | ||||||||
FirstName: | BRENTON | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 120 W GERMANTOWN PIKE STE 100 | ||||||||
Address2: |   | ||||||||
City: | PLYMOUTH MEETING | ||||||||
State: | PA | ||||||||
PostalCode: | 194621420 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102700370 | ||||||||
FaxNumber: | 6102700374 | ||||||||
Practice Location | |||||||||
Address1: | 528 KIMBERTON RD | ||||||||
Address2: |   | ||||||||
City: | PHOENIXVILLE | ||||||||
State: | PA | ||||||||
PostalCode: | 194604737 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6109336232 | ||||||||
FaxNumber: | 6109336234 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/02/2018 | ||||||||
LastUpdateDate: | 08/02/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2251X0800X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic |
No ID Information.