1124000401 NPI number — BRUCE'S BODY SHOP INC.

Table of content: (NPI 1124000401)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124000401 NPI number — BRUCE'S BODY SHOP INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRUCE'S BODY SHOP INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
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:
1124000401
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 148
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MARYSVILLE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
66508-0148
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
785-562-2359
Provider Business Mailing Address Fax Number:
785-562-3159

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1204 CENTER ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYSVILLE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
66508-1727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
785-562-2359
Provider Business Practice Location Address Fax Number:
785-562-3159
Provider Enumeration Date:
11/14/2005

Additional Information

Authorized Official

Authorized Official Last Name:
KELLER
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
785-562-2359

Provider Taxonomy Codes

  • Taxonomy code: 146L00000X , with the licence number:  1180 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00000112016 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".




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