Provider Demographics
NPI:1316369861
Name:KITCHEN, BRUCE (LMP)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:KITCHEN
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23203 E KILLARNEY LAKE RD
Mailing Address - Street 2:
Mailing Address - City:CATALDO
Mailing Address - State:ID
Mailing Address - Zip Code:83810-9324
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:13403 N GOVERNMENT WAY
Practice Address - Street 2:
Practice Address - City:HAYDEN LAKE
Practice Address - State:ID
Practice Address - Zip Code:83835-9460
Practice Address - Country:US
Practice Address - Phone:208-215-9372
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-16
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMASG-1028225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist