1255712048 NPI number — EDWARD JONATHAN BREIGHT M.S., ATC

Table of content: EDWARD JONATHAN BREIGHT M.S., ATC (NPI 1255712048)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255712048 NPI number — EDWARD JONATHAN BREIGHT M.S., ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BREIGHT
Provider First Name:
EDWARD
Provider Middle Name:
JONATHAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.S., ATC
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:
1255712048
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
520 VINE DR APT 8C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWOOD
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39232-7744
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
661-466-3262
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1325 EAST FORTICATION STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39202
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-466-3262
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/17/2015

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: 2255A2300X , with the licence number:  2000009324 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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