Provider Demographics
NPI:1578046090
Name:BREALON LIRETTE LLC
Entity Type:Organization
Organization Name:BREALON LIRETTE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BREALON
Authorized Official - Middle Name:M
Authorized Official - Last Name:LIRETTE
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:985-804-0678
Mailing Address - Street 1:242 WOODWIND DR
Mailing Address - Street 2:
Mailing Address - City:HOUMA
Mailing Address - State:LA
Mailing Address - Zip Code:70360-3996
Mailing Address - Country:US
Mailing Address - Phone:337-643-8424
Mailing Address - Fax:337-643-8407
Practice Address - Street 1:242 WOODWIND DR
Practice Address - Street 2:
Practice Address - City:HOUMA
Practice Address - State:LA
Practice Address - Zip Code:70360-3996
Practice Address - Country:US
Practice Address - Phone:337-643-8424
Practice Address - Fax:337-643-8407
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-11
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2456067Medicaid