Healthcare Provider Details

I. General information

NPI: 1114792637
Provider Name (Legal Business Name): BRONCHE JERARD TAYLOR I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2023
Last Update Date: 12/18/2023
Certification Date: 12/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 E 12TH ST STE 259
OAKLAND CA
94601-2940
US

IV. Provider business mailing address

311 9TH AVE UNIT 310
OAKLAND CA
94606-5198
US

V. Phone/Fax

Practice location:
  • Phone: 510-846-0099
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: