Provider Demographics
NPI:1720100415
Name:BREAULT, KACIE A (OD)
Entity Type:Individual
Prefix:DR
First Name:KACIE
Middle Name:A
Last Name:BREAULT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:133 N POMPANO BEACH BLVD
Mailing Address - Street 2:APT. 1404
Mailing Address - City:POMPANO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33062-5720
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1601 SAWGRASS CORPORATE PKWY
Practice Address - Street 2:SUITE 410
Practice Address - City:SUNRISE
Practice Address - State:FL
Practice Address - Zip Code:33323-2883
Practice Address - Country:US
Practice Address - Phone:954-835-0800
Practice Address - Fax:954-835-0885
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4002152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist