Provider Demographics
NPI:1417158312
Name:LARRY BREAZEL OD PA
Entity Type:Organization
Organization Name:LARRY BREAZEL OD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:D
Authorized Official - Last Name:BREAZEAL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:509-922-2400
Mailing Address - Street 1:509 N SULLIVAN RD STE G
Mailing Address - Street 2:
Mailing Address - City:SPOKANE VALLEY
Mailing Address - State:WA
Mailing Address - Zip Code:99037-8566
Mailing Address - Country:US
Mailing Address - Phone:509-922-2400
Mailing Address - Fax:509-922-1577
Practice Address - Street 1:509 N SULLIVAN RD STE G
Practice Address - Street 2:
Practice Address - City:SPOKANE VALLEY
Practice Address - State:WA
Practice Address - Zip Code:99037-8566
Practice Address - Country:US
Practice Address - Phone:509-922-2400
Practice Address - Fax:509-922-1577
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-29
Last Update Date:2012-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA602451136152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2029882Medicaid
WA2029882Medicaid