Provider Demographics
NPI:1497972566
Name:BREWERTON, LAWRENCE
Entity Type:Individual
Prefix:
First Name:LAWRENCE
Middle Name:
Last Name:BREWERTON
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 1:8670 LANTERN DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9671
Mailing Address - Country:US
Mailing Address - Phone:847-673-0718
Mailing Address - Fax:847-673-0875
Practice Address - Street 1:10352 N 600 E
Practice Address - Street 2:
Practice Address - City:DEMOTTE
Practice Address - State:IN
Practice Address - Zip Code:46310-8959
Practice Address - Country:US
Practice Address - Phone:219-345-5811
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility