Basic Information
| Provider Information | |||||||||
| NPI: | 1750331013 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRUCE E MULLEN A PROFESSIONAL CORPORATION | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SPINECARE AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 755 N ROOP ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897013107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758837938 | ||||||||
| FaxNumber: | 7758830907 | ||||||||
| Practice Location | |||||||||
| Address1: | 755 N ROOP ST STE 112 | ||||||||
| Address2: | |||||||||
| City: | CARSON CITY | ||||||||
| State: | NV | ||||||||
| PostalCode: | 897013107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7758837938 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/10/2006 | ||||||||
| LastUpdateDate: | 05/11/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MULLEN | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7758837938 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
| NPICertificationDate: | 05/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | NV | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 100505821 | 05 | NV | MEDICAID |