Provider Demographics
NPI:1285330886
Name:BRUNI, SHANE
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:
Last Name:BRUNI
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 1:3S266 BRIARWOOD DR
Mailing Address - Street 2:
Mailing Address - City:WARRENVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60555-2623
Mailing Address - Country:US
Mailing Address - Phone:630-779-8658
Mailing Address - Fax:
Practice Address - Street 1:2000 OAKBROOK CTR
Practice Address - Street 2:
Practice Address - City:OAK BROOK
Practice Address - State:IL
Practice Address - Zip Code:60523-9002
Practice Address - Country:US
Practice Address - Phone:630-203-5458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013965111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty