Provider Demographics
NPI:1811685464
Name:BRUNO- FREDERIKSEN, MITCHELL
Entity type:Individual
Prefix:
First Name:MITCHELL
Middle Name:
Last Name:BRUNO- FREDERIKSEN
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 1:648 COVE BLVD
Mailing Address - Street 2:
Mailing Address - City:COVENTRY TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:44319-1042
Mailing Address - Country:US
Mailing Address - Phone:330-553-4584
Mailing Address - Fax:
Practice Address - Street 1:648 COVE BLVD
Practice Address - Street 2:
Practice Address - City:COVENTRY TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:44319-1042
Practice Address - Country:US
Practice Address - Phone:330-553-4584
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-01
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist