Provider Demographics
NPI:1841331691
Name:BREIWA WARE & JESKIE PSC
Entity type:Organization
Organization Name:BREIWA WARE & JESKIE PSC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:N
Authorized Official - Last Name:BREIWA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-842-0383
Mailing Address - Street 1:P.O. BOX 5000
Mailing Address - Street 2:335 NEW TOWNE DRIVE
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-7966
Mailing Address - Country:US
Mailing Address - Phone:270-842-0383
Mailing Address - Fax:270-842-0485
Practice Address - Street 1:335 NEW TOWNE RD
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7966
Practice Address - Country:US
Practice Address - Phone:270-842-0383
Practice Address - Fax:270-842-0485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-12
Last Update Date:2018-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
No332H00000XSuppliersEyewear SupplierGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100253310Medicaid
KY06622OtherSPECTERA
KY77903201Medicaid
KY8765Medicare ID - Type UnspecifiedGROUP #