1114060308 NPI number — DIANE BRUCE OD

Table of content: DIANE BRUCE OD (NPI 1114060308)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114060308 NPI number — DIANE BRUCE OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCE
Provider First Name:
DIANE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114060308
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/10/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5250 LAUREL TER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FLOWERY BRANCH
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30542-5238
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
198 SW BROAD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JESUP
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31545-1101
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
912-530-6000
Provider Business Practice Location Address Fax Number:
912-530-6044
Provider Enumeration Date:
02/15/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152WC0802X , with the licence number:  OPT001278 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 814827714E , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2024 www.npivalidator.com