1568428308 NPI number — MR. DAVID LAWRENCE BRUNKEN ATC

Table of content: MR. DAVID LAWRENCE BRUNKEN ATC (NPI 1568428308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568428308 NPI number — MR. DAVID LAWRENCE BRUNKEN ATC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUNKEN
Provider First Name:
DAVID
Provider Middle Name:
LAWRENCE
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ATC
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1568428308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
27628 ROCKWOOD AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MORENO VALLEY
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92555-5732
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-487-3598
Provider Business Mailing Address Fax Number:
951-654-4572

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1499 N STATE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN JACINTO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92583-2325
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
951-487-3598
Provider Business Practice Location Address Fax Number:
951-654-4572
Provider Enumeration Date:
04/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2255A2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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