MEDICARE: DERA, INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1710915731
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERA, INC

Provider Business Mailing Address
First Line	:	513 E COLISEUM BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1215
Country	:	US
Telephone Number	:	260-484-8966
Fax Number	:	260-484-0508

Provider Business Practice Location Address
First Line	:	513 E COLISEUM BLVD
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46805-1215
Country	:	US
Telephone Number	:	260-484-8966
Fax Number	:	260-484-0508

Authorized Official
Title or Position	:	OWNER
Name	:	DOUGLAS REX BRUICK
Credential	:	C.PED.
Telephone Number	:	260-484-8966

Provider Enumeration Date	:	06/29/2006
Last Update Date	:	04/13/2012

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