1144666439 NPI number — BREEN HEALTH, LLC

Table of content: (NPI 1144666439)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1144666439 NPI number — BREEN HEALTH, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREEN HEALTH, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
COMMUNITY FAMILY HEALTH CARE
Provider Other Organization Name Type Code:
3
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:
1144666439
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
11392 NE HIGHWAY 316
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT MCCOY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32134-8114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-236-0440
Provider Business Mailing Address Fax Number:
352-236-0717

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11392 NE HIGHWAY 316
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FORT MCCOY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32134-0000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-236-0440
Provider Business Practice Location Address Fax Number:
352-236-0717
Provider Enumeration Date:
05/14/2013

Additional Information

Authorized Official

Authorized Official Last Name:
SMITH
Authorized Official First Name:
SONDRA
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT/OWNER
Authorized Official Telephone Number:
786-409-8387

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 683830 . This is a "PTAN" identifier , issued by the state of ( FL ) . This identifiers is of the category "OTHER".




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