Provider Demographics
NPI:1760483259
Name:BRUNELLO, CARL VICTOR (DC)
Entity Type:Individual
Prefix:MR
First Name:CARL
Middle Name:VICTOR
Last Name:BRUNELLO
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E SMITH RD
Mailing Address - Street 2:STE A
Mailing Address - City:MEDINA
Mailing Address - State:OH
Mailing Address - Zip Code:44256-2666
Mailing Address - Country:US
Mailing Address - Phone:330-725-4500
Mailing Address - Fax:330-725-4504
Practice Address - Street 1:600 E SMITH RD
Practice Address - Street 2:STE A
Practice Address - City:MEDINA
Practice Address - State:OH
Practice Address - Zip Code:44256-2666
Practice Address - Country:US
Practice Address - Phone:330-725-4500
Practice Address - Fax:330-725-4504
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH899111N00000X
GA1812111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000131840OtherANTHEM
OH478666Medicaid
OH341436169001OtherMEDICAL MUTUAL
OH81439OtherQUALCHOICE
OH000000131840OtherANTHEM
OH478666Medicaid