Provider Demographics
NPI:1114743077
Name:BRUNNER, JOHN
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BRUNNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6576 35TH PL
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32966-7810
Mailing Address - Country:US
Mailing Address - Phone:765-414-3041
Mailing Address - Fax:
Practice Address - Street 1:6576 35TH PL
Practice Address - Street 2:
Practice Address - City:VERO BEACH
Practice Address - State:FL
Practice Address - Zip Code:32966-7810
Practice Address - Country:US
Practice Address - Phone:765-414-3041
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-25
Last Update Date:2024-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA100406225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist