Healthcare Provider Details

I. General information

NPI: 1578046090
Provider Name (Legal Business Name): BREALON LIRETTE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 04/27/2020
Certification Date: 04/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

242 WOODWIND DR
HOUMA LA
70360-3996
US

IV. Provider business mailing address

242 WOODWIND DR
HOUMA LA
70360-3996
US

V. Phone/Fax

Practice location:
  • Phone: 337-643-8424
  • Fax: 337-643-8407
Mailing address:
  • Phone: 337-643-8424
  • Fax: 337-643-8407

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: BREALON M LIRETTE
Title or Position: OWNER
Credential: APRN
Phone: 985-804-0678