1750089330 NPI number — BREERIC LLC

Table of content: (NPI 1750089330)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750089330 NPI number — BREERIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BREERIC 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:
Provider Other Organization Name Type Code:
6
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:
1750089330
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/04/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
809 PROFESSIONAL PLACE, BLDG A
Provider Second Line Business Mailing Address:
UNIT 103
Provider Business Mailing Address City Name:
CHESAPEAKE
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23320
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-362-1157
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1109 S MILITARY HWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHESAPEAKE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23320-2347
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-362-1157
Provider Business Practice Location Address Fax Number:
757-260-7988
Provider Enumeration Date:
02/22/2023

Additional Information

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
SABRINA
Authorized Official Middle Name:
ANN
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
757-362-1157

Provider Taxonomy Codes

  • Taxonomy code: 251J00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QA0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 343900000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 30017627240002 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: HCO263306 . This is a "STATE LICENSE" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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