Healthcare Provider Details

I. General information

NPI: 1265785588
Provider Name (Legal Business Name): JONATHAN EDWARD BRUNO B.C.B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/24/2012
Last Update Date: 05/18/2021
Certification Date: 05/18/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2825 W RUMBLE RD
MODESTO CA
95350-0185
US

IV. Provider business mailing address

2630 W RUMBLE RD
MODESTO CA
95350-0155
US

V. Phone/Fax

Practice location:
  • Phone: 209-222-2378
  • Fax: 209-579-9494
Mailing address:
  • Phone: 209-222-2378
  • Fax: 209-579-9494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number1-10-6985
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: