=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851518336
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | EMARJUN BRUCAL PT, MHA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2007
-----------------------------------------------------
Last Update Date | 12/02/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 132 W 4TH AVE
-----------------------------------------------------
City | WILLIAMSON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25661-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-235-2389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 132 W 4TH AVE
-----------------------------------------------------
City | WILLIAMSON
-----------------------------------------------------
State | WV
-----------------------------------------------------
Zip | 25661-3112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 304-235-2389
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 004562
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------