Healthcare Provider Details

I. General information

NPI: 1689943854
Provider Name (Legal Business Name): BRUCE ELLIOTT MOCK JR. PHD, AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/17/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 WRIGHTSVILLE AVE # 110
WILMINGTON NC
28403-6241
US

IV. Provider business mailing address

970 MALLARD BAY RD
HAMPSTEAD NC
28443-2584
US

V. Phone/Fax

Practice location:
  • Phone: 910-791-4755
  • Fax:
Mailing address:
  • Phone: 910-270-2961
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License Number9794
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number9794
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: