Provider Demographics
NPI:1396112876
Name:BRUCE-BLACK, NATHANIEL (HAD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:BRUCE-BLACK
Suffix:
Gender:M
Credentials:HAD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10650 SCRIPPS RANCH BLVD STE 108
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92131-2471
Mailing Address - Country:US
Mailing Address - Phone:858-348-4044
Mailing Address - Fax:
Practice Address - Street 1:16777 BERNARDO CENTER DR
Practice Address - Street 2:E9
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-2572
Practice Address - Country:US
Practice Address - Phone:858-676-0635
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-31
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA8009237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist