Healthcare Provider Details

I. General information

NPI: 1457865677
Provider Name (Legal Business Name): MATTHEW BRUNS BERILLA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/27/2017
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50249 CESAR CHAVEZ ST STE K
COACHELLA CA
92236-1530
US

IV. Provider business mailing address

50249 CESAR CHAVEZ ST STE K
COACHELLA CA
92236-1530
US

V. Phone/Fax

Practice location:
  • Phone: 760-393-0555
  • Fax: 760-393-0522
Mailing address:
  • Phone: 760-393-0555
  • Fax: 760-393-0522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number60198
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: