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General NPI Number Information
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NPI Number | 1912031535
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Entity Type | Individual
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Provider Name | BRUCE GARY RUSS L.AC., M.S.T.O.M.
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Gender | Male
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Dates
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Enumeration Date | 03/15/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 23331 EL TORO RD SUITE 106
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City | LAKE FOREST
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State | CA
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Zip | 92630-4891
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Country | US
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Telephone | 949-859-9696
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Fax | 949-859-1951
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Provider Business Mailing Address
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Address Line | 24112 BIRDROCK DR
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City | LAKE FOREST
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State | CA
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Zip | 92630-4403
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Country | US
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Telephone | 949-707-5330
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Fax | 949-859-1951
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 171100000X
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Taxonomy Name | Acupuncturist
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License Number | AC 8877
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License Number State | CA
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