Provider Demographics
NPI:1609032424
Name:BRERETON, HENRY LESTER JR (CST, CFA)
Entity Type:Individual
Prefix:
First Name:HENRY
Middle Name:LESTER
Last Name:BRERETON
Suffix:JR
Gender:M
Credentials:CST, CFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224 W ERIE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:AR
Mailing Address - Zip Code:72601-3539
Mailing Address - Country:US
Mailing Address - Phone:870-741-8289
Mailing Address - Fax:870-741-0308
Practice Address - Street 1:224 W ERIE AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:AR
Practice Address - Zip Code:72601-3539
Practice Address - Country:US
Practice Address - Phone:870-741-8289
Practice Address - Fax:870-741-0308
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2008-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR108730246ZC0007X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZC0007XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherSurgical Assistant