Provider Demographics
NPI:1891151643
Name:BRUZAS, PETER (LAT, ATC, CSCS)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:
Last Name:BRUZAS
Suffix:
Gender:M
Credentials:LAT, ATC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 N ATKINSON AVE APT 15
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:NM
Mailing Address - Zip Code:88201-7819
Mailing Address - Country:US
Mailing Address - Phone:704-249-5685
Mailing Address - Fax:
Practice Address - Street 1:113 E COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:NM
Practice Address - Zip Code:88201-5158
Practice Address - Country:US
Practice Address - Phone:575-622-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-09
Last Update Date:2016-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM6132255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer