Healthcare Provider Details

I. General information

NPI: 1477236230
Provider Name (Legal Business Name): BRUCE LORNE RAYMOND RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/09/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 PREBLE ST
PORTLAND ME
04101-2426
US

IV. Provider business mailing address

160 PREBLE ST
PORTLAND ME
04101-2426
US

V. Phone/Fax

Practice location:
  • Phone: 207-523-9276
  • Fax: 888-245-3952
Mailing address:
  • Phone: 207-523-9276
  • Fax: 888-245-3952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License NumberRN79259
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: