Healthcare Provider Details

I. General information

NPI: 1114652476
Provider Name (Legal Business Name): BRUNETTE BASTIEN MEDICAL SERVICES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2022
Last Update Date: 02/01/2023
Certification Date: 02/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 VISCAYA PKWY STE 101
CAPE CORAL FL
33990-3294
US

IV. Provider business mailing address

1425 VISCAYA PKWY STE 101
CAPE CORAL FL
33990-3294
US

V. Phone/Fax

Practice location:
  • Phone: 239-293-5829
  • Fax: 239-236-1200
Mailing address:
  • Phone: 239-919-4851
  • Fax: 239-236-1200

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: MS. BRUNETTE BASTIEN
Title or Position: OWNER
Credential:
Phone: 239-919-4851