Provider Demographics
NPI:1982726634
Name:BROUILLETTE, SAMUEL P (CP, CFO)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:P
Last Name:BROUILLETTE
Suffix:
Gender:M
Credentials:CP, CFO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1279 WILLOWBREEZE CT
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-8975
Mailing Address - Country:US
Mailing Address - Phone:980-622-8266
Mailing Address - Fax:
Practice Address - Street 1:1524 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2509
Practice Address - Country:US
Practice Address - Phone:704-334-1860
Practice Address - Fax:704-347-2785
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7795146Medicaid
NC7700566Medicaid
NC7795145Medicaid
NC7795145Medicaid