Healthcare Provider Details

I. General information

NPI: 1316567100
Provider Name (Legal Business Name): ALICE M BRONER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2020
Last Update Date: 04/21/2020
Certification Date: 04/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

292 EUCLID AVE STE 210
SAN DIEGO CA
92114-3629
US

IV. Provider business mailing address

PO BOX 740243
SAN DIEGO CA
92174-0243
US

V. Phone/Fax

Practice location:
  • Phone: 619-266-3665
  • Fax:
Mailing address:
  • Phone: 619-417-4427
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: