Healthcare Provider Details

I. General information

NPI: 1508917683
Provider Name (Legal Business Name): MITCHELL JAMES BRUNING PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 01/18/2021
Certification Date: 01/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4141 E THOMAS RD
PHOENIX AZ
85018-7515
US

IV. Provider business mailing address

PO BOX 15858
PHOENIX AZ
85060-5858
US

V. Phone/Fax

Practice location:
  • Phone: 602-954-7742
  • Fax: 602-955-2229
Mailing address:
  • Phone: 602-954-7742
  • Fax: 602-955-2229

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number3369
License Number StateAZ
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number3369
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: