Provider Demographics
NPI:1174767396
Name:BREEDLOVE, WESLEY JAMES (CHA 3)
Entity type:Individual
Prefix:MR
First Name:WESLEY
Middle Name:JAMES
Last Name:BREEDLOVE
Suffix:
Gender:M
Credentials:CHA 3
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5508
Mailing Address - Street 2:
Mailing Address - City:PORT GRAHAM
Mailing Address - State:AK
Mailing Address - Zip Code:99603-5508
Mailing Address - Country:US
Mailing Address - Phone:907-284-2241
Mailing Address - Fax:907-284-2277
Practice Address - Street 1:5530 GRAHAM ROAD
Practice Address - Street 2:
Practice Address - City:PORT GRAHAM
Practice Address - State:AK
Practice Address - Zip Code:99603
Practice Address - Country:US
Practice Address - Phone:907-284-2241
Practice Address - Fax:907-284-2277
Is Sole Proprietor?:No
Enumeration Date:2009-05-01
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK08-948-11172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker