Healthcare Provider Details

I. General information

NPI: 1760483259
Provider Name (Legal Business Name): CARL VICTOR BRUNELLO DC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/09/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 E SMITH RD STE A
MEDINA OH
44256-2666
US

IV. Provider business mailing address

600 E SMITH RD STE A
MEDINA OH
44256-2666
US

V. Phone/Fax

Practice location:
  • Phone: 330-725-4500
  • Fax: 330-725-4504
Mailing address:
  • Phone: 330-725-4500
  • Fax: 330-725-4504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number899
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1812
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: