Provider Demographics
NPI:1982453163
Name:BRUCE, CASEY
Entity type:Individual
Prefix:
First Name:CASEY
Middle Name:
Last Name:BRUCE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1355 S MCCORD RD
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:OH
Mailing Address - Zip Code:43528-9141
Mailing Address - Country:US
Mailing Address - Phone:419-867-0544
Mailing Address - Fax:419-867-0604
Practice Address - Street 1:1355 S MCCORD RD
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:OH
Practice Address - Zip Code:43528-9141
Practice Address - Country:US
Practice Address - Phone:419-867-0544
Practice Address - Fax:419-867-0604
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHOP.017753-S156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician