Provider Demographics
NPI:1104348614
Name:BREAST RECON SPECIALISTS, PLLC
Entity type:Organization
Organization Name:BREAST RECON SPECIALISTS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:JON
Authorized Official - Middle Name:
Authorized Official - Last Name:VER HALEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-416-8080
Mailing Address - Street 1:1717 WISTERIA WAY
Mailing Address - Street 2:
Mailing Address - City:WESTLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76262-9083
Mailing Address - Country:US
Mailing Address - Phone:206-963-8714
Mailing Address - Fax:
Practice Address - Street 1:7167 COLLEYVILLE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-8002
Practice Address - Country:US
Practice Address - Phone:817-484-0169
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-17
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty