Healthcare Provider Details

I. General information

NPI: 1982726634
Provider Name (Legal Business Name): SAMUEL P BROUILLETTE C.P., C.F.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 ELIZABETH AVE
CHARLOTTE NC
28204-2509
US

IV. Provider business mailing address

1279 WILLOWBREEZE CT
CONCORD NC
28025-8975
US

V. Phone/Fax

Practice location:
  • Phone: 704-334-1860
  • Fax: 704-347-2785
Mailing address:
  • Phone: 980-622-8266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: