Healthcare Provider Details

I. General information

NPI: 1841331691
Provider Name (Legal Business Name): BREIWA WARE & JESKIE PSC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

335 NEW TOWNE RD
BOWLING GREEN KY
42103-7966
US

IV. Provider business mailing address

P.O. BOX 5000 335 NEW TOWNE DRIVE
BOWLING GREEN KY
42103-7966
US

V. Phone/Fax

Practice location:
  • Phone: 270-842-0383
  • Fax: 270-842-0485
Mailing address:
  • Phone: 270-842-0383
  • Fax: 270-842-0485

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332H00000X
TaxonomyEyewear Supplier
License Number
License Number State

VIII. Authorized Official

Name: DR. JOHN N. BREIWA
Title or Position: PRESIDENT
Credential: O.D.
Phone: 270-842-0383