Healthcare Provider Details

I. General information

NPI: 1104095975
Provider Name (Legal Business Name): DEBRUIN MEDICAL CENTER A.P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 02/26/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9352 MADISON AVE STE. ONE
ORANGEVALE CA
95662-4968
US

IV. Provider business mailing address

9352 MADISON AVE STE. ONE
ORANGEVALE CA
95662-4968
US

V. Phone/Fax

Practice location:
  • Phone: 916-989-2929
  • Fax: 916-989-0322
Mailing address:
  • Phone: 916-989-2929
  • Fax: 916-989-0322

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A5579
License Number StateCA

VIII. Authorized Official

Name: DR. MARK IKE DEBRUIN
Title or Position: OWNER
Credential: D.O.
Phone: 916-989-2929