Provider Demographics
NPI:1649567322
Name:MATTHEWS, BRUCE R (MA 60231903)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:R
Last Name:MATTHEWS
Suffix:
Gender:M
Credentials:MA 60231903
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14002 NE 7TH WAY
Mailing Address - Street 2:
Mailing Address - City:VANCOUVER
Mailing Address - State:WA
Mailing Address - Zip Code:98684-7341
Mailing Address - Country:US
Mailing Address - Phone:360-852-1765
Mailing Address - Fax:
Practice Address - Street 1:16111 SE MCGILLIVRAY BLVD STE A
Practice Address - Street 2:
Practice Address - City:VANCOUVER
Practice Address - State:WA
Practice Address - Zip Code:98683-9033
Practice Address - Country:US
Practice Address - Phone:360-254-0994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA 60231903225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist