Provider Demographics
NPI:1265626113
Name:PARKS, BRUCE (LVN)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:
Last Name:PARKS
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 B ST
Mailing Address - Street 2:1580
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-4520
Mailing Address - Country:US
Mailing Address - Phone:619-916-0439
Mailing Address - Fax:
Practice Address - Street 1:600 B ST
Practice Address - Street 2:1580
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-4520
Practice Address - Country:US
Practice Address - Phone:619-916-0439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-09-04
Last Update Date:2007-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA194917164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse