Provider Demographics
NPI:1003483678
Name:BREEN, MARK
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:BREEN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1230 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:LOWELL
Mailing Address - State:MA
Mailing Address - Zip Code:01850-1291
Mailing Address - Country:US
Mailing Address - Phone:978-455-3397
Mailing Address - Fax:
Practice Address - Street 1:1230 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:LOWELL
Practice Address - State:MA
Practice Address - Zip Code:01850-1291
Practice Address - Country:US
Practice Address - Phone:978-455-3397
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-10
Last Update Date:2021-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist