Healthcare Provider Details

I. General information

NPI: 1861828691
Provider Name (Legal Business Name): MR. BRUCE RAY HAMMER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2013
Last Update Date: 09/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4235 BEACH ST
DELAVAN WI
53115-3335
US

IV. Provider business mailing address

4235 BEACH ST
DELAVAN WI
53115-3335
US

V. Phone/Fax

Practice location:
  • Phone: 630-330-3815
  • Fax: 800-513-1494
Mailing address:
  • Phone: 630-330-3815
  • Fax: 800-513-1494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number13-00012412
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: