Healthcare Provider Details

I. General information

NPI: 1902637135
Provider Name (Legal Business Name): BREANA LYNN FAIR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2024
Last Update Date: 09/10/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

393 WASHINGTON AVE UNIT B
GOLDEN CO
80403-1889
US

IV. Provider business mailing address

393 WASHINGTON AVE UNIT B
GOLDEN CO
80403-1889
US

V. Phone/Fax

Practice location:
  • Phone: 720-307-7707
  • Fax:
Mailing address:
  • Phone: 720-307-7707
  • Fax: 720-307-7702

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPTL.0020104
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: