Healthcare Provider Details

I. General information

NPI: 1265401673
Provider Name (Legal Business Name): RANDY SCOTT BREIDEL SUB IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

DAM NECK ANNEX 1885 TERRIER AVE STE 100
VIRGINIA BEACH VA
23461-2298
US

IV. Provider business mailing address

761 DWYER RD
VIRGINIA BEACH VA
23454-6924
US

V. Phone/Fax

Practice location:
  • Phone: 757-314-7221
  • Fax:
Mailing address:
  • Phone: 757-689-8742
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: