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General NPI Number Information
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NPI Number | 1336496777
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Entity Type | Organization
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Legal Business Name | BREITER TECH CORP
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Dates
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Enumeration Date | 08/03/2012
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Last Update Date | 08/03/2012
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Provider Practice Location Address
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Address Line | 640 GEORGE WASHINGTON HWY
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City | LINCOLN
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State | RI
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Zip | 02865-4332
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Country | US
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Telephone | 216-386-3815
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Fax |
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Provider Business Mailing Address
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Address Line | 640 GEORGE WASHINGTON HWY
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City | LINCOLN
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State | RI
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Zip | 02865-4332
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Country | US
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Telephone | 216-386-3815
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | STEFAN GRAVENSTEIN
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Credential |
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Telephone | 216-386-3815
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 12353
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License Number State | RI
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