Provider Demographics
NPI:1487104600
Name:BRUCE COOK PROSTHETICS
Entity type:Organization
Organization Name:BRUCE COOK PROSTHETICS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/OCULARIST
Authorized Official - Prefix:
Authorized Official - First Name:WRAY
Authorized Official - Middle Name:BRUCE
Authorized Official - Last Name:COOK
Authorized Official - Suffix:
Authorized Official - Credentials:BCO
Authorized Official - Phone:314-567-7585
Mailing Address - Street 1:2821 N BALLAS RD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-2321
Mailing Address - Country:US
Mailing Address - Phone:314-567-7585
Mailing Address - Fax:
Practice Address - Street 1:2821 N BALLAS RD
Practice Address - Street 2:SUITE 215
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-2321
Practice Address - Country:US
Practice Address - Phone:314-567-7585
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO156FX1700X332BC3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0508940001Medicare NSC