Provider Demographics
NPI:1912031535
Name:RUSS, BRUCE GARY (LAC, MSTOM)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:GARY
Last Name:RUSS
Suffix:
Gender:M
Credentials:LAC, MSTOM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24112 BIRDROCK DR
Mailing Address - Street 2:
Mailing Address - City:LAKE FOREST
Mailing Address - State:CA
Mailing Address - Zip Code:92630-4403
Mailing Address - Country:US
Mailing Address - Phone:949-707-5330
Mailing Address - Fax:949-859-1951
Practice Address - Street 1:23331 EL TORO RD
Practice Address - Street 2:SUITE 106
Practice Address - City:LAKE FOREST
Practice Address - State:CA
Practice Address - Zip Code:92630-4891
Practice Address - Country:US
Practice Address - Phone:949-859-9696
Practice Address - Fax:949-859-1951
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8877171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist