1700958303 NPI number — MRS. VICTORIA SUZANNE BRUCE OTRL

Table of content: MRS. VICTORIA SUZANNE BRUCE OTRL (NPI 1700958303)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700958303 NPI number — MRS. VICTORIA SUZANNE BRUCE OTRL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRUCE
Provider First Name:
VICTORIA
Provider Middle Name:
SUZANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
OTRL
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
POWELL
Provider Other First Name:
VICTORIA
Provider Other Middle Name:
SUZANNE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OTRL
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1700958303
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2104 WINSBURG DR NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KENNESAW
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30144-5227
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
770-418-1778
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3483 SATELLITE BLVD
Provider Second Line Business Practice Location Address:
SUITE 304
Provider Business Practice Location Address City Name:
DULUTH
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
30096-8692
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
770-418-1778
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/15/2006

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: 171W00000X , with the licence number:  OT004367 , 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)





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