MEDICARE: BRUCE LIRONES DO PROFESSIONAL LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	5101008200	MI

General Provider Information

NPI Number	:	1215250071
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BRUCE LIRONES DO PROFESSIONAL LLC

Provider Business Mailing Address
First Line	:	9895 RAPID CITY RD NW
Second Line	:
City	:	RAPID CITY
State	:	MI
Zip	:	49676-9506
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	9895 RAPID CITY RD NW
Second Line	:
City	:	RAPID CITY
State	:	MI
Zip	:	49676-9506
Country	:	US
Telephone Number	:	231-331-4283
Fax Number	:

Authorized Official
Title or Position	:	SOLE MEMBER
Name	:	BRUCE LIRONES
Credential	:
Telephone Number	:	231-331-4283

Provider Enumeration Date	:	03/09/2010
Last Update Date	:	03/09/2010

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