Provider Demographics
NPI:1538847397
Name:TAYLOR, BRUCE THUNDER
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:THUNDER
Last Name:TAYLOR
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 1:1501 ARKANSAS AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-6407
Mailing Address - Country:US
Mailing Address - Phone:318-692-0225
Mailing Address - Fax:
Practice Address - Street 1:1501 ARKANSAS AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-6407
Practice Address - Country:US
Practice Address - Phone:318-692-0225
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-10
Last Update Date:2024-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA7490212172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty