Healthcare Provider Details

I. General information

NPI: 1801509997
Provider Name (Legal Business Name): BURNETT L BRAKE PRSS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2023
Last Update Date: 01/04/2023
Certification Date: 01/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1511 WASHINGTON ST E
CHARLESTON WV
25311-2505
US

IV. Provider business mailing address

1514 KANAWHA BLVD W
CHARLESTON WV
25387-2533
US

V. Phone/Fax

Practice location:
  • Phone: 304-741-7106
  • Fax:
Mailing address:
  • Phone: 304-768-7688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: