Provider Demographics
NPI:1174024715
Name:BRUCE, LACRETIA
Entity Type:Individual
Prefix:
First Name:LACRETIA
Middle Name:
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 1:12 FOX RUN DR
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72210-7133
Mailing Address - Country:US
Mailing Address - Phone:501-765-7951
Mailing Address - Fax:
Practice Address - Street 1:12 FOX RUN DR
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72210-7133
Practice Address - Country:US
Practice Address - Phone:501-765-7951
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-27
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities