Provider Demographics
NPI:1114652476
Name:BRUNETTE BASTIEN MEDICAL SERVICES LLC
Entity Type:Organization
Organization Name:BRUNETTE BASTIEN MEDICAL SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:BRUNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:BASTIEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:239-919-4851
Mailing Address - Street 1:1425 VISCAYA PKWY STE 101
Mailing Address - Street 2:
Mailing Address - City:CAPE CORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33990-3294
Mailing Address - Country:US
Mailing Address - Phone:239-919-4851
Mailing Address - Fax:239-236-1200
Practice Address - Street 1:1425 VISCAYA PKWY STE 101
Practice Address - Street 2:
Practice Address - City:CAPE CORAL
Practice Address - State:FL
Practice Address - Zip Code:33990-3294
Practice Address - Country:US
Practice Address - Phone:239-293-5829
Practice Address - Fax:239-236-1200
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-07-20
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)Group - Single Specialty
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty