Provider Demographics
NPI:1184232563
Name:BREEDLOVE, DWAYNE (HIS)
Entity Type:Individual
Prefix:
First Name:DWAYNE
Middle Name:
Last Name:BREEDLOVE
Suffix:
Gender:M
Credentials:HIS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4807 E GREENWAY RD STE 3
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85254-9608
Mailing Address - Country:US
Mailing Address - Phone:602-765-7800
Mailing Address - Fax:
Practice Address - Street 1:4807 E GREENWAY RD STE 3
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85254-9608
Practice Address - Country:US
Practice Address - Phone:602-765-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-07-21
Last Update Date:2020-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZHADE9268237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist