Healthcare Provider Details

I. General information

NPI: 1104018860
Provider Name (Legal Business Name): BRUCE A ANDERSON
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/15/2007
Last Update Date: 01/17/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 W 3RD ST
ALLIANCE NE
69301-3125
US

IV. Provider business mailing address

PO BOX 830
ALLIANCE NE
69301-0830
US

V. Phone/Fax

Practice location:
  • Phone: 308-762-4056
  • Fax: 308-762-4063
Mailing address:
  • Phone: 308-762-4056
  • Fax: 308-762-4063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number967
License Number StateNE

VIII. Authorized Official

Name: DR. BRUCE A ANDERSON
Title or Position: OWNER
Credential: O.D.
Phone: 308-762-4056