Basic Information
| Provider Information | |||||||||
| NPI: | 1215383682 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | BROUSSARD | ||||||||
| FirstName: | BRETT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1086 TEANECK RD | ||||||||
| Address2: | STE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 1086 TEANECK RD | ||||||||
| Address2: | STE 4A | ||||||||
| City: | TEANECK | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 076664854 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2018629900 | ||||||||
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| ProviderEnumerationDate: | 05/04/2016 | ||||||||
| LastUpdateDate: | 05/04/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246ZE0600X | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.