Healthcare Provider Details

I. General information

NPI: 1770506461
Provider Name (Legal Business Name): BRUCE ALVIN RIOUX CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 SOMERSET ST
MILLINOCKET ME
04462-1258
US

IV. Provider business mailing address

200 SOMERSET ST
MILLINOCKET ME
04462-1258
US

V. Phone/Fax

Practice location:
  • Phone: 207-723-5161
  • Fax:
Mailing address:
  • Phone: 207-723-5161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberR025863
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: