Provider Demographics
NPI:1689877839
Name:BREEN, ROBERT P (OPTICIAN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:BREEN
Suffix:
Gender:M
Credentials:OPTICIAN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1303 N 25TH ST
Mailing Address - Street 2:
Mailing Address - City:BETHANY
Mailing Address - State:MO
Mailing Address - Zip Code:64424-1509
Mailing Address - Country:US
Mailing Address - Phone:660-425-2317
Mailing Address - Fax:
Practice Address - Street 1:1303 N 25TH ST
Practice Address - Street 2:
Practice Address - City:BETHANY
Practice Address - State:MO
Practice Address - Zip Code:64424-1509
Practice Address - Country:US
Practice Address - Phone:660-425-2317
Practice Address - Fax:660-425-2317
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-06
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
5544160001Medicare NSC