Provider Demographics
NPI:1104976182
Name:MCCLELLAN, BRUCE PATRICK (CPO)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:PATRICK
Last Name:MCCLELLAN
Suffix:
Gender:M
Credentials:CPO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1122 E FRONT ST
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75702-8414
Mailing Address - Country:US
Mailing Address - Phone:903-592-6574
Mailing Address - Fax:903-595-3862
Practice Address - Street 1:1122 E FRONT ST
Practice Address - Street 2:
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702-8414
Practice Address - Country:US
Practice Address - Phone:903-592-6574
Practice Address - Fax:903-595-3862
Is Sole Proprietor?:No
Enumeration Date:2007-01-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX25222Z00000X, 224P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist
Not Answered224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist