Provider Demographics
NPI:1700061124
Name:GAINES, BRUCE LEE (PT, DPT)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:LEE
Last Name:GAINES
Suffix:
Gender:M
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4804 96TH ST
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79424-4819
Mailing Address - Country:US
Mailing Address - Phone:806-438-1203
Mailing Address - Fax:806-794-6566
Practice Address - Street 1:4804 96TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79424-4819
Practice Address - Country:US
Practice Address - Phone:806-438-1203
Practice Address - Fax:806-794-6566
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-03
Last Update Date:2008-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1032993225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX650479Medicare PIN