Provider Demographics
NPI:1033565544
Name:BRERETON, PHILIP JOHN (CO)
Entity Type:Individual
Prefix:MR
First Name:PHILIP
Middle Name:JOHN
Last Name:BRERETON
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:961 MATLEY LN STE 100
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89502-2100
Mailing Address - Country:US
Mailing Address - Phone:775-323-8118
Mailing Address - Fax:775-323-1234
Practice Address - Street 1:466 E HARDING WAY
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204
Practice Address - Country:US
Practice Address - Phone:209-466-2546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-13
Last Update Date:2016-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVC52250222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist