Provider Demographics
NPI:1912576356
Name:BRUNET, ETHAN JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:ETHAN
Middle Name:JOHN
Last Name:BRUNET
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:PO BOX 1044
Mailing Address - Street 2:
Mailing Address - City:ROBERTSDALE
Mailing Address - State:AL
Mailing Address - Zip Code:36567-1044
Mailing Address - Country:US
Mailing Address - Phone:850-910-2832
Mailing Address - Fax:
Practice Address - Street 1:18557 E HAMMOND ST
Practice Address - Street 2:
Practice Address - City:ROBERTSDALE
Practice Address - State:AL
Practice Address - Zip Code:36567-3629
Practice Address - Country:US
Practice Address - Phone:251-947-9010
Practice Address - Fax:251-947-9011
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH05056111N00000X
AL2727111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor