Healthcare Provider Details

I. General information

NPI: 1891196200
Provider Name (Legal Business Name): JOHN MITCHELL BRUKETA ATC, AT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2014
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

215 W BOWERY ST STE 7300
AKRON OH
44308-1020
US

IV. Provider business mailing address

215 WEST BOWERY STREET, SUITE 7300
AKRON OH
44308
US

V. Phone/Fax

Practice location:
  • Phone: 330-543-8260
  • Fax:
Mailing address:
  • Phone: 330-543-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: