Provider Demographics
NPI:1851743827
Name:UNDERWOOD, BRUCE CALVIN (DRPH,MSE,MPH)
Entity type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:CALVIN
Last Name:UNDERWOOD
Suffix:
Gender:M
Credentials:DRPH,MSE,MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75895 ALTAMIRA DR
Mailing Address - Street 2:
Mailing Address - City:INDIAN WELLS
Mailing Address - State:CA
Mailing Address - Zip Code:92210-8768
Mailing Address - Country:US
Mailing Address - Phone:760-238-1446
Mailing Address - Fax:760-773-9706
Practice Address - Street 1:75895 ALTAMIRA DR
Practice Address - Street 2:
Practice Address - City:INDIAN WELLS
Practice Address - State:CA
Practice Address - Zip Code:92210-8768
Practice Address - Country:US
Practice Address - Phone:760-238-1446
Practice Address - Fax:760-773-9706
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-01
Last Update Date:2016-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA101Y00000X, 133N00000X, 133NN1002X, 174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No101Y00000XBehavioral Health & Social Service ProvidersCounselor
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No174H00000XOther Service ProvidersHealth Educator