Healthcare Provider Details

I. General information

NPI: 1518525583
Provider Name (Legal Business Name): WILLIAM EDWARD MCBREEN JR. SFIDC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2019
Last Update Date: 01/23/2020
Certification Date: 01/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

COASTAL RIVERINE GROUP 1 DETACHMENT GUAM
FPO AP
96540-1400
US

IV. Provider business mailing address

1263 MYRTLE AVE
SAN DIEGO CA
92103-5114
US

V. Phone/Fax

Practice location:
  • Phone: 671-339-2336
  • Fax:
Mailing address:
  • Phone: 619-772-0484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: