Provider Demographics
NPI:1184331860
Name:LADD, BRUCE PRENTISS (LAC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:PRENTISS
Last Name:LADD
Suffix:
Gender:M
Credentials:LAC
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 522
Mailing Address - Street 2:
Mailing Address - City:YACHATS
Mailing Address - State:OR
Mailing Address - Zip Code:97498-0522
Mailing Address - Country:US
Mailing Address - Phone:541-270-8540
Mailing Address - Fax:
Practice Address - Street 1:2118 HIGHWAY 101 N BLDG 1
Practice Address - Street 2:
Practice Address - City:YACHATS
Practice Address - State:OR
Practice Address - Zip Code:97498-9416
Practice Address - Country:US
Practice Address - Phone:541-547-2285
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2022-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC207669171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist