Provider Demographics
NPI:1508515560
Name:BRUNO, JEROME MARK
Entity Type:Individual
Prefix:MR
First Name:JEROME
Middle Name:MARK
Last Name:BRUNO
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 1:529 POTIER RD LOT B
Mailing Address - Street 2:
Mailing Address - City:CARENCRO
Mailing Address - State:LA
Mailing Address - Zip Code:70520-6237
Mailing Address - Country:US
Mailing Address - Phone:337-520-1813
Mailing Address - Fax:225-831-9664
Practice Address - Street 1:216 8TH ST
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70501-7163
Practice Address - Country:US
Practice Address - Phone:985-397-0290
Practice Address - Fax:225-931-9664
Is Sole Proprietor?:Yes
Enumeration Date:2022-03-18
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA11718243747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1171824Medicaid