Provider Demographics
NPI:1891176616
Name:BRUCE D. LEVINE, D.P.M., PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE D. LEVINE, D.P.M., PROFESSIONAL CORPORATION
Other - Org Name:HARBOR FOOT & ANKLE PODIATRIC MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEVINE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:310-548-1191
Mailing Address - Street 1:2980 N BEVERLY GLEN CIR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90077-1726
Mailing Address - Country:US
Mailing Address - Phone:310-943-4180
Mailing Address - Fax:888-431-8819
Practice Address - Street 1:1360 W 6TH ST
Practice Address - Street 2:SUITE 150, WEST BUILDING
Practice Address - City:SAN PEDRO
Practice Address - State:CA
Practice Address - Zip Code:90732-3514
Practice Address - Country:US
Practice Address - Phone:310-548-1191
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRUCE D. LEVINE, D.P.M., PROFESSIONAL CORPORATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-06-17
Last Update Date:2015-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3485332900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site