Basic Information
| Provider Information | |||||||||
| NPI: | 1174767396 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BREEDLOVE | ||||||||
| FirstName: | WESLEY | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | CHA 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5508 | ||||||||
| Address2: | |||||||||
| City: | PORT GRAHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 996035508 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072842241 | ||||||||
| FaxNumber: | 9072842277 | ||||||||
| Practice Location | |||||||||
| Address1: | 5530 GRAHAM ROAD | ||||||||
| Address2: | |||||||||
| City: | PORT GRAHAM | ||||||||
| State: | AK | ||||||||
| PostalCode: | 99603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9072842241 | ||||||||
| FaxNumber: | 9072842277 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2009 | ||||||||
| LastUpdateDate: | 05/01/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | 08-948-11 | AK | Y | Other Service Providers | Community Health Worker |
No ID Information.