Healthcare Provider Details

I. General information

NPI: 1033977830
Provider Name (Legal Business Name): BRANNATA WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2024
Last Update Date: 08/12/2025
Certification Date: 08/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 S DOBSON RD STE D31-D35
CHANDLER AZ
85224-5678
US

IV. Provider business mailing address

545 SW 2ND ST STE 201
CORVALLIS OR
97333-4466
US

V. Phone/Fax

Practice location:
  • Phone: 541-816-1049
  • Fax:
Mailing address:
  • Phone: 541-816-1049
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number
License Number State

VIII. Authorized Official

Name: MANNY CRUZ
Title or Position: OWNER
Credential:
Phone: 541-760-4775