MEDICARE: KELLY BRUCE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164X00000X	Licensed Vocational Nurse	165690	TX

General Provider Information

NPI Number	:	1629699558
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY BRUCE

Provider Business Mailing Address
First Line	:	1155 DAIRY ASHFORD RD STE 560
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77079-3035
Country	:	US
Telephone Number	:	713-799-2200
Fax Number	:

Provider Business Practice Location Address
First Line	:	1445 EL CAMINO VILLAGE DR
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77058-3071
Country	:	US
Telephone Number	:	409-392-4559
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/01/2020
Last Update Date	:	05/01/2020

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