Provider Demographics
NPI:1942776877
Name:EBNET, BRECKAN NICHOLAS
Entity Type:Individual
Prefix:
First Name:BRECKAN
Middle Name:NICHOLAS
Last Name:EBNET
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 1:510 3RD STREET WEST
Mailing Address - Street 2:
Mailing Address - City:LAKE LILLIAN
Mailing Address - State:MN
Mailing Address - Zip Code:56253
Mailing Address - Country:US
Mailing Address - Phone:320-905-0383
Mailing Address - Fax:
Practice Address - Street 1:800 W COLLEGE AVE
Practice Address - Street 2:
Practice Address - City:SAINT PETER
Practice Address - State:MN
Practice Address - Zip Code:56082
Practice Address - Country:US
Practice Address - Phone:320-905-0383
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-18
Last Update Date:2018-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer