1104882729 NPI number — BRUCE M PRENNER MD

Table of content: BRUCE M PRENNER MD (NPI 1104882729)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104882729 NPI number — BRUCE M PRENNER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PRENNER
Provider First Name:
BRUCE
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
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:
1104882729
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/10/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2305
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SKYLAND
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28776-2305
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
828-575-2644
Provider Business Mailing Address Fax Number:
828-350-2174

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2655 CAMINO DEL RIO N
Provider Second Line Business Practice Location Address:
# 120
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92108-1633
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-286-6687
Provider Business Practice Location Address Fax Number:
619-286-6695
Provider Enumeration Date:
04/22/2006

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: 207K00000X , with the licence number:  G21931 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00G219310 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: GW214Z . This is a "MEDICARE PTAN" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com