Provider Demographics
NPI:1013564285
Name:BRUCE, OCTAVIA ELISA
Entity Type:Individual
Prefix:
First Name:OCTAVIA
Middle Name:ELISA
Last Name:BRUCE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:808 GREEN SPRINGS HWY
Mailing Address - Street 2:SUITE 124 STUDIO 4
Mailing Address - City:HOMEWOOD
Mailing Address - State:AL
Mailing Address - Zip Code:35216
Mailing Address - Country:US
Mailing Address - Phone:205-862-8696
Mailing Address - Fax:
Practice Address - Street 1:808 GREEN SPRINGS HWY
Practice Address - Street 2:SUITE 124 STUDIO 4
Practice Address - City:HOMEWOOD
Practice Address - State:AL
Practice Address - Zip Code:35216
Practice Address - Country:US
Practice Address - Phone:205-862-8696
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-22
Last Update Date:2019-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty