Provider Demographics
NPI:1609033026
Name:BRUCE W PIERSON
Entity Type:Organization
Organization Name:BRUCE W PIERSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:W
Authorized Official - Last Name:PIERSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:814-849-4602
Mailing Address - Street 1:130 PICKERING ST
Mailing Address - Street 2:
Mailing Address - City:BROOKVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:15825-0804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:130 PICKERING ST
Practice Address - Street 2:
Practice Address - City:BROOKVILLE
Practice Address - State:PA
Practice Address - Zip Code:15825-0804
Practice Address - Country:US
Practice Address - Phone:814-849-4602
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-22
Last Update Date:2008-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000043332H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332H00000XSuppliersEyewear Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010041200001Medicaid
PA166225Medicare PIN
PA0010041200001Medicaid
PA0237660001Medicare NSC