Healthcare Provider Details

I. General information

NPI: 1801884879
Provider Name (Legal Business Name): BRUCE ALLEN PERRY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/12/2005
Last Update Date: 07/31/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

124 16TH ST NE
FAYETTE AL
35555-1340
US

IV. Provider business mailing address

124 16TH ST NE
FAYETTE AL
35555-1340
US

V. Phone/Fax

Practice location:
  • Phone: 205-932-5286
  • Fax: 205-932-8577
Mailing address:
  • Phone: 205-932-5286
  • Fax: 205-932-8577

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS449TA072
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: