Provider Demographics
NPI:1396084307
Name:ROSWITHA BREUER A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:ROSWITHA BREUER A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ROSWITHA
Authorized Official - Middle Name:ELISABETH
Authorized Official - Last Name:BREUER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:951-956-2152
Mailing Address - Street 1:146 E 4TH ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92570-2125
Mailing Address - Country:US
Mailing Address - Phone:951-956-2152
Mailing Address - Fax:951-956-2154
Practice Address - Street 1:146 E 4TH ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92570-2125
Practice Address - Country:US
Practice Address - Phone:951-956-2152
Practice Address - Fax:951-956-2154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-11
Last Update Date:2022-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA362361261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A362360Medicaid
CA00A362360Medicaid