Provider Demographics
NPI:1144384850
Name:BRUNENGRABER, SCOTT ERIC (DC)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:ERIC
Last Name:BRUNENGRABER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:285 E MAIN ST
Mailing Address - Street 2:SUITE LL-6
Mailing Address - City:SMITHTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:11787-2978
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:285 E MAIN ST
Practice Address - Street 2:SUITE LL-6
Practice Address - City:SMITHTOWN
Practice Address - State:NY
Practice Address - Zip Code:11787-2978
Practice Address - Country:US
Practice Address - Phone:631-361-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX009316111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX4U-381Medicare UPIN