Provider Demographics
NPI:1649874678
Name:COWIN CARTER, BRUCE
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:COWIN CARTER
Suffix:
Gender:M
Credentials:
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 646
Mailing Address - Street 2:
Mailing Address - City:WILLIAMSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45176-0646
Mailing Address - Country:US
Mailing Address - Phone:513-724-7448
Mailing Address - Fax:513-724-1174
Practice Address - Street 1:4096 DELA PALMA RD
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:OH
Practice Address - Zip Code:45176-9712
Practice Address - Country:US
Practice Address - Phone:513-724-7448
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-30
Last Update Date:2020-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1301040310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2504310Medicaid