Healthcare Provider Details

I. General information

NPI: 1407508161
Provider Name (Legal Business Name): BRE ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 10/19/2024
Certification Date: 10/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 GIBSON STREET, NW SUITE 123
LEESBURG VA
20176-2115
US

IV. Provider business mailing address

211 GIBSON STREET, NW SUITE 123
LEESBURG VA
20176-2115
US

V. Phone/Fax

Practice location:
  • Phone: 571-561-3040
  • Fax:
Mailing address:
  • Phone: 703-795-8793
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083A0300X
TaxonomyAddiction Medicine (Preventive Medicine) Physician
License Number
License Number State

VIII. Authorized Official

Name: HEATHER JEFFERSON
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 703-314-7846