Healthcare Provider Details

I. General information

NPI: 1063580082
Provider Name (Legal Business Name): JOHN KENNEDY BRUNS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 04/22/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9488 SHORE RD
FISH CREEK WI
54212-9696
US

IV. Provider business mailing address

9488 SHORE RD
FISH CREEK WI
54212-9696
US

V. Phone/Fax

Practice location:
  • Phone: 920-912-2563
  • Fax:
Mailing address:
  • Phone: 920-912-2563
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NI0900X
TaxonomyInternist Chiropractor
License Number4088-012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: