Provider Demographics
NPI:1689988347
Name:BRUZZESE, DOMENIC JON
Entity Type:Individual
Prefix:
First Name:DOMENIC
Middle Name:JON
Last Name:BRUZZESE
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 1:2250 ALCAZAR ST # ST-133
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-9068
Mailing Address - Country:US
Mailing Address - Phone:323-442-3340
Mailing Address - Fax:323-442-3351
Practice Address - Street 1:2250 ALCAZAR ST # ST-133
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-9068
Practice Address - Country:US
Practice Address - Phone:323-442-3340
Practice Address - Fax:323-442-3351
Is Sole Proprietor?:No
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11366225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist