Provider Demographics
NPI:1801810049
Name:BRUNOLLI, JOHN MICHAEL (PT)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:BRUNOLLI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22636 CEDAR PINES AVE
Mailing Address - Street 2:
Mailing Address - City:TWAIN HARTE
Mailing Address - State:CA
Mailing Address - Zip Code:95383-9549
Mailing Address - Country:US
Mailing Address - Phone:209-586-8944
Mailing Address - Fax:
Practice Address - Street 1:13808 MONO WAY
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8864
Practice Address - Country:US
Practice Address - Phone:209-532-2928
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 19605225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PT196050Medicare ID - Type Unspecified