=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073602256
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BRUNER TAMMY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/12/2006
-----------------------------------------------------
Last Update Date | 06/19/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 119 N BALDWIN AVE
-----------------------------------------------------
City | MARION
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46952
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 765-664-7463
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30 EMS C30 LANE
-----------------------------------------------------
City | WARSAW
-----------------------------------------------------
State | IN
-----------------------------------------------------
Zip | 46582
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 574-269-3306
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | RN OWNER
-----------------------------------------------------
Name | TAMMY R BRUNER
-----------------------------------------------------
Credential | RN
-----------------------------------------------------
Telephone | 574-269-3306
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 335E00000X
-----------------------------------------------------
Taxonomy Name | Prosthetic/Orthotic Supplier
-----------------------------------------------------
License Number | 28060524A
-----------------------------------------------------
License Number State | IN
-----------------------------------------------------