Healthcare Provider Details

I. General information

NPI: 1326217761
Provider Name (Legal Business Name): ANDREW JAMES BRETH RT (R)
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2008
Last Update Date: 02/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

43302 170TH AVE
HOLDINGFORD MN
56340-9738
US

V. Phone/Fax

Practice location:
  • Phone: 320-255-6480
  • Fax:
Mailing address:
  • Phone: 320-293-9915
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2471C3402X
TaxonomyRadiography Radiologic Technologist
License Number429801
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: