Provider Demographics
NPI:1740050822
Name:BRUNCUSO HOLDINGS CHAPTER TWO LLC
Entity type:Organization
Organization Name:BRUNCUSO HOLDINGS CHAPTER TWO LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/OPERATOR
Authorized Official - Prefix:
Authorized Official - First Name:TRACI
Authorized Official - Middle Name:
Authorized Official - Last Name:MANCUSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:206-755-6699
Mailing Address - Street 1:4425 E VILLA CASSANDRA WAY
Mailing Address - Street 2:
Mailing Address - City:CAVE CREEK
Mailing Address - State:AZ
Mailing Address - Zip Code:85331-9564
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4425 E VILLA CASSANDRA WAY
Practice Address - Street 2:
Practice Address - City:CAVE CREEK
Practice Address - State:AZ
Practice Address - Zip Code:85331-9564
Practice Address - Country:US
Practice Address - Phone:206-755-6699
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRUNCUSO HOLDINGS CHAPTER TWO LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-01-08
Last Update Date:2024-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty