Provider Demographics
NPI:1780716274
Name:DAVIS, BRUCE TERRIEL (LPN)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:TERRIEL
Last Name:DAVIS
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:416 COVE BEACH AVE
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD LAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44054-1819
Mailing Address - Country:US
Mailing Address - Phone:440-949-3090
Mailing Address - Fax:440-332-3820
Practice Address - Street 1:416 COVE BEACH AVE
Practice Address - Street 2:
Practice Address - City:SHEFFIELD LAKE
Practice Address - State:OH
Practice Address - Zip Code:44054-1819
Practice Address - Country:US
Practice Address - Phone:216-403-5413
Practice Address - Fax:440-332-3820
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-10
Last Update Date:2010-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN102551164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH271-66-72Medicaid