1861728602 NPI number — MR. JERE CLIFTON BREWER CADAC-II

Table of content: MR. JERE CLIFTON BREWER CADAC-II (NPI 1861728602)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861728602 NPI number — MR. JERE CLIFTON BREWER CADAC-II

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREWER
Provider First Name:
JERE
Provider Middle Name:
CLIFTON
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
CADAC-II
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861728602
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9601 REDWOOD BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CALIFORNIA CITY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93505-3675
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-499-7838
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4301 W MARKHAM ST # 835
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LITTLE ROCK
Provider Business Practice Location Address State Name:
AR
Provider Business Practice Location Address Postal Code:
72205-7101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
501-526-8422
Provider Business Practice Location Address Fax Number:
501-526-8499
Provider Enumeration Date:
10/29/2009

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X , with the licence number:  RA858109 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 119945 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 101YA0400X , with the licence number: 1559 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)