Provider Demographics
NPI:1013909779
Name:SNOW, BRUCE RANDOLPH (PT,MS,OSC)
Entity Type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:RANDOLPH
Last Name:SNOW
Suffix:
Gender:M
Credentials:PT,MS,OSC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:AL
Mailing Address - Zip Code:36545-0037
Mailing Address - Country:US
Mailing Address - Phone:251-246-5761
Mailing Address - Fax:251-246-3779
Practice Address - Street 1:295 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:GROVE HILL
Practice Address - State:AL
Practice Address - Zip Code:36451-3231
Practice Address - Country:US
Practice Address - Phone:251-275-4905
Practice Address - Fax:251-275-7906
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL4140225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP89881Medicare UPIN