Healthcare Provider Details

I. General information

NPI: 1003314873
Provider Name (Legal Business Name): HENDRIK BREYTENBACH MD INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/26/2018
Last Update Date: 01/26/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 POSADA LN STE D
TEMPLETON CA
93465-4054
US

IV. Provider business mailing address

292 POSADA LN STE D
TEMPLETON CA
93465-4054
US

V. Phone/Fax

Practice location:
  • Phone: 805-434-3791
  • Fax: 805-434-2019
Mailing address:
  • Phone: 805-434-3791
  • Fax: 805-434-2019

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA69161
License Number StateCA

VIII. Authorized Official

Name: CRISSY MACKINGA
Title or Position: OFFICE MANAGER
Credential:
Phone: 805-434-3791