Provider Demographics
NPI:1457048811
Name:TENREIRO, BROOKE
Entity type:Individual
Prefix:
First Name:BROOKE
Middle Name:
Last Name:TENREIRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:142 GERARD RD
Mailing Address - Street 2:
Mailing Address - City:YAPHANK
Mailing Address - State:NY
Mailing Address - Zip Code:11980-9772
Mailing Address - Country:US
Mailing Address - Phone:631-559-9784
Mailing Address - Fax:
Practice Address - Street 1:142 GERARD RD
Practice Address - Street 2:
Practice Address - City:YAPHANK
Practice Address - State:NY
Practice Address - Zip Code:11980-9772
Practice Address - Country:US
Practice Address - Phone:631-559-9784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-18
Last Update Date:2023-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1682619231174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist