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General NPI Number Information
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NPI Number | 1417158312
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Entity Type | Organization
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Legal Business Name | LARRY BREAZEL OD PA
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Dates
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Enumeration Date | 05/29/2007
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Last Update Date | 07/03/2012
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Provider Practice Location Address
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Address Line | 509 N SULLIVAN RD STE G
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City | SPOKANE VALLEY
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State | WA
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Zip | 99037-8566
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Country | US
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Telephone | 509-922-2400
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Fax | 509-922-1577
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Provider Business Mailing Address
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Address Line | 509 N SULLIVAN RD STE G
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City | SPOKANE VALLEY
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State | WA
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Zip | 99037-8566
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Country | US
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Telephone | 509-922-2400
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Fax | 509-922-1577
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Authorized Official
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Title or Position | OWNER
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Name | LARRY D BREAZEAL
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Credential | O.D.
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Telephone | 509-922-2400
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 602451136
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License Number State | WA
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