Healthcare Provider Details

I. General information

NPI: 1881706075
Provider Name (Legal Business Name): DONALD BRUENJES ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2301 25TH ST S
FARGO ND
58103-6104
US

IV. Provider business mailing address

2301 25TH ST S
FARGO ND
58103-6104
US

V. Phone/Fax

Practice location:
  • Phone: 701-237-9712
  • Fax: 701-237-0922
Mailing address:
  • Phone: 701-237-9712
  • Fax: 701-237-0922

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number30-86
License Number StateND
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1932
License Number StateMN

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: