Provider Demographics
NPI:1811124092
Name:BRECKENRIDGE, VIRGIL EARL JR
Entity type:Individual
Prefix:MR
First Name:VIRGIL
Middle Name:EARL
Last Name:BRECKENRIDGE
Suffix:JR
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 1:2605 TORCH AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89081-6557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4700 LAS VEGAS BLVD NORTH
Practice Address - Street 2:
Practice Address - City:NELLIS AFB
Practice Address - State:NV
Practice Address - Zip Code:89191-6601
Practice Address - Country:US
Practice Address - Phone:702-653-3512
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-16
Last Update Date:2009-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX709223163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse