Basic Information
Provider Information
NPI: 1003004367
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: REEVES
FirstName: BRUCE
MiddleName: ALAN
NamePrefix: MR.
NameSuffix:  
Credential: PT
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 169 ASHLEY AVE
Address2: ROOM, 3SW WING
City: CHARLESTON
State: SC
PostalCode: 294258905
CountryCode: US
TelephoneNumber: 8437923481
FaxNumber: 8437920724
Practice Location
Address1: 169 ASHLEY AVE
Address2: ROOM, 3SW WING
City: CHARLESTON
State: SC
PostalCode: 294258905
CountryCode: US
TelephoneNumber: 8437923481
FaxNumber: 8437920724
Other Information
ProviderEnumerationDate: 10/11/2007
LastUpdateDate: 10/11/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
2251X0800X3104SCY Respiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic

No ID Information.


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