Provider Demographics
NPI:1346273877
Name:HAL W BREEDLOVE OD PC
Entity Type:Organization
Organization Name:HAL W BREEDLOVE OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:HAL
Authorized Official - Middle Name:W
Authorized Official - Last Name:BREEDLOVE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:757-426-2020
Mailing Address - Street 1:1729 WILDWOOD DRIVE
Mailing Address - Street 2:SUITE 101
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23454
Mailing Address - Country:US
Mailing Address - Phone:757-426-2020
Mailing Address - Fax:757-481-1964
Practice Address - Street 1:1729 WILDWOOD DR
Practice Address - Street 2:SUITE 101
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3176
Practice Address - Country:US
Practice Address - Phone:757-426-2020
Practice Address - Fax:757-481-1964
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-08
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
0618000633152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1679505861Medicaid
VA0917400001Medicare NSC
VA1679505861Medicaid
VAC09961Medicare PIN