Provider Demographics
NPI:1548574221
Name:GONSETH, BRUCE ALLEN SR (LMT)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:ALLEN
Last Name:GONSETH
Suffix:SR
Gender:M
Credentials:LMT
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Mailing Address - Street 1:23222 NE 159TH AVE
Mailing Address - Street 2:
Mailing Address - City:FORT MC COY
Mailing Address - State:FL
Mailing Address - Zip Code:32134-8359
Mailing Address - Country:US
Mailing Address - Phone:352-546-5659
Mailing Address - Fax:352-369-1122
Practice Address - Street 1:611 NE 25TH AVE
Practice Address - Street 2:
Practice Address - City:OCALA
Practice Address - State:FL
Practice Address - Zip Code:34470-7033
Practice Address - Country:US
Practice Address - Phone:352-362-9469
Practice Address - Fax:352-369-1122
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-04
Last Update Date:2010-08-04
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLMA59342225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist