1588135040 NPI number — MR. ROBERT ERNEST BRUCE JR. LSW

Table of content: MR. ROBERT ERNEST BRUCE JR. LSW (NPI 1588135040)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588135040 NPI number — MR. ROBERT ERNEST BRUCE JR. LSW

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCE
Provider First Name:
ROBERT
Provider Middle Name:
ERNEST
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
LSW
Provider Gender Code:
M

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:
1588135040
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/10/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1785 BIG HILL RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DAYTON
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45439-2219
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-264-0084
Provider Business Mailing Address Fax Number:
937-264-0095

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2081 DRUMMOND DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
XENIA
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45385-4023
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-264-0084
Provider Business Practice Location Address Fax Number:
937-264-0095
Provider Enumeration Date:
12/10/2018

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: 104100000X , with the licence number:  S.1101315 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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