Healthcare Provider Details

I. General information

NPI: 1487104600
Provider Name (Legal Business Name): BRUCE COOK PROSTHETICS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/12/2016
Last Update Date: 10/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2821 N BALLAS RD SUITE 215
SAINT LOUIS MO
63131-2321
US

IV. Provider business mailing address

2821 N BALLAS RD SUITE 215
SAINT LOUIS MO
63131-2321
US

V. Phone/Fax

Practice location:
  • Phone: 314-567-7585
  • Fax:
Mailing address:
  • Phone: 314-567-7585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number156FX1700X
License Number StateMO

VIII. Authorized Official

Name: WRAY BRUCE COOK
Title or Position: OWNER/OCULARIST
Credential: B.C.O.
Phone: 314-567-7585