Provider Demographics
NPI:1184019069
Name:WALLS, BRUCE
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WALLS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 CRANFIELD RD
Mailing Address - Street 2:
Mailing Address - City:ROXIE
Mailing Address - State:MS
Mailing Address - Zip Code:39661-9662
Mailing Address - Country:US
Mailing Address - Phone:601-660-0962
Mailing Address - Fax:
Practice Address - Street 1:104 CRANFIELD RD
Practice Address - Street 2:
Practice Address - City:ROXIE
Practice Address - State:MS
Practice Address - Zip Code:39661-9662
Practice Address - Country:US
Practice Address - Phone:601-660-0962
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-30
Last Update Date:2015-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider