Provider Demographics
NPI:1235234972
Name:BRUNCKHORST, BRIAN K
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:K
Last Name:BRUNCKHORST
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 1:225 INVERNESS CIR
Mailing Address - Street 2:
Mailing Address - City:CHALFONT
Mailing Address - State:PA
Mailing Address - Zip Code:18914-3919
Mailing Address - Country:US
Mailing Address - Phone:201-456-8534
Mailing Address - Fax:
Practice Address - Street 1:1 W RIDGEWOOD AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-2359
Practice Address - Country:US
Practice Address - Phone:201-652-1415
Practice Address - Fax:201-652-0391
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2022-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01149200225100000X
PAPT030388225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist