Healthcare Provider Details

I. General information

NPI: 1124000401
Provider Name (Legal Business Name): BRUCE'S BODY SHOP INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1204 CENTER ST
MARYSVILLE KS
66508-1727
US

IV. Provider business mailing address

PO BOX 148
MARYSVILLE KS
66508-0148
US

V. Phone/Fax

Practice location:
  • Phone: 785-562-2359
  • Fax: 785-562-3159
Mailing address:
  • Phone: 785-562-2359
  • Fax: 785-562-3159

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code146L00000X
TaxonomyParamedic
License Number1180
License Number StateKS

VIII. Authorized Official

Name: MR. JAMES L KELLER
Title or Position: PRESIDENT
Credential:
Phone: 785-562-2359