Provider Demographics
NPI:1073698577
Name:O'BRIEN, BRUCE E (CPO)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:E
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:611 LOVINGGOOD TRL
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-7413
Mailing Address - Country:US
Mailing Address - Phone:770-928-0763
Mailing Address - Fax:
Practice Address - Street 1:102 HINES ROAD
Practice Address - Street 2:
Practice Address - City:CALHOUN
Practice Address - State:GA
Practice Address - Zip Code:30701
Practice Address - Country:US
Practice Address - Phone:770-928-0763
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA000011335E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier