Provider Demographics
NPI:1508202805
Name:BRISENO, DAN
Entity Type:Individual
Prefix:
First Name:DAN
Middle Name:
Last Name:BRISENO
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 1:935 S. HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:427 HIGHWAY 49
Practice Address - Street 2:305
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-5666
Practice Address - Country:US
Practice Address - Phone:209-533-1397
Practice Address - Fax:209-533-1034
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator