Provider Demographics
NPI:1841748647
Name:BREW MEDICAL AND REJUVENATION CLINIC LLC
Entity Type:Organization
Organization Name:BREW MEDICAL AND REJUVENATION CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:TULIE
Authorized Official - Middle Name:P
Authorized Official - Last Name:BREW
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:203-244-9529
Mailing Address - Street 1:27 HOSPITAL AVE
Mailing Address - Street 2:SUITE 403
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-5954
Mailing Address - Country:US
Mailing Address - Phone:203-244-9529
Mailing Address - Fax:203-355-7147
Practice Address - Street 1:27 HOSPITAL AVE
Practice Address - Street 2:SUITE 403
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-5954
Practice Address - Country:US
Practice Address - Phone:203-244-9529
Practice Address - Fax:203-355-7147
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-09-21
Last Update Date:2017-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006337174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTD400277831Medicare PIN