MEDICARE: MR. MATTHEW L. BRESKE SFIDC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1710I1002X	Independent Duty Corpsman

General Provider Information

NPI Number	:	1982848040
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. MATTHEW L. BRESKE SFIDC

Provider Business Mailing Address
First Line	:	7791 MERCURY RD
Second Line	:	FAIRECONRON FOUR
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73145-8712
Country	:	US
Telephone Number	:	405-734-2914
Fax Number	:

Provider Business Practice Location Address
First Line	:	7791 MERCURY RD
Second Line	:	FAIRECONRON FOUR
City	:	OKLAHOMA CITY
State	:	OK
Zip	:	73145-8712
Country	:	US
Telephone Number	:	405-582-6615
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/20/2009
Last Update Date	:	04/29/2013

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