Provider Demographics
NPI:1578110235
Name:BERRUN, CHRISTOPHER A
Entity type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:A
Last Name:BERRUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21935 VAN BUREN ST
Mailing Address - Street 2:
Mailing Address - City:GRAND TERRACE
Mailing Address - State:CA
Mailing Address - Zip Code:92313-5652
Mailing Address - Country:US
Mailing Address - Phone:951-567-4915
Mailing Address - Fax:
Practice Address - Street 1:21935 VAN BUREN ST
Practice Address - Street 2:
Practice Address - City:GRAND TERRACE
Practice Address - State:CA
Practice Address - Zip Code:92313-5652
Practice Address - Country:US
Practice Address - Phone:951-567-4915
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-19
Last Update Date:2024-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA171M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator