Provider Demographics
NPI:1497293393
Name:BRACAMONTE, RUEBEN
Entity Type:Individual
Prefix:
First Name:RUEBEN
Middle Name:
Last Name:BRACAMONTE
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 1:258 N BLACKSTONE AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93701-1913
Mailing Address - Country:US
Mailing Address - Phone:559-274-0299
Mailing Address - Fax:
Practice Address - Street 1:3855 N WEST AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93705-2759
Practice Address - Country:US
Practice Address - Phone:559-274-0299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-10
Last Update Date:2020-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA258202164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse