Provider Demographics
NPI:1326133935
Name:GRONSETH, BRUCE CARL
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:CARL
Last Name:GRONSETH
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 1:7508 DEERFIELD RD. NW
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-4530
Mailing Address - Country:US
Mailing Address - Phone:505-899-8331
Mailing Address - Fax:
Practice Address - Street 1:2100 RIDGECREST DRIVE SE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87108
Practice Address - Country:US
Practice Address - Phone:505-265-1711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2061225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist