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General NPI Number Information
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NPI Number | 1487104600
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Entity Type | Organization
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Legal Business Name | BRUCE COOK PROSTHETICS
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Dates
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Enumeration Date | 10/12/2016
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Last Update Date | 10/12/2016
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Provider Practice Location Address
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Address Line | 2821 N BALLAS RD SUITE 215
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City | SAINT LOUIS
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State | MO
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Zip | 63131-2321
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Country | US
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Telephone | 314-567-7585
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Fax |
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Provider Business Mailing Address
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Address Line | 2821 N BALLAS RD SUITE 215
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City | SAINT LOUIS
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State | MO
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Zip | 63131-2321
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Country | US
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Telephone | 314-567-7585
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Fax |
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Authorized Official
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Title or Position | OWNER/OCULARIST
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Name | WRAY BRUCE COOK
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Credential | B.C.O.
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Telephone | 314-567-7585
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 332BC3200X
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Taxonomy Name | Customized Equipment (DME)
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License Number | 156FX1700X
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License Number State | MO
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