Basic Information
Provider Information | |||||||||
NPI: | 1669634721 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | BRENTON MANAGEMENT GROUP INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 425 | ||||||||
Address2: |   | ||||||||
City: | WHITEVILLE | ||||||||
State: | NC | ||||||||
PostalCode: | 284720425 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106410600 | ||||||||
FaxNumber: | 9106410606 | ||||||||
Practice Location | |||||||||
Address1: | 203 CHAUNCEY TOWN ROAD | ||||||||
Address2: |   | ||||||||
City: | LAKE WACCAMAW | ||||||||
State: | NC | ||||||||
PostalCode: | 284502003 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9106410600 | ||||||||
FaxNumber: | 9106410606 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/30/2008 | ||||||||
LastUpdateDate: | 06/30/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BYRD | ||||||||
AuthorizedOfficialFirstName: | BRENTON | ||||||||
AuthorizedOfficialMiddleName: | BLAKE | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9106410600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BX2000X |   |   | Y |   | Suppliers | Durable Medical Equipment & Medical Supplies | Oxygen Equipment & Supplies |
No ID Information.