Provider Demographics
NPI:1679657829
Name:DIVEN, BRUCE C (PT)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:C
Last Name:DIVEN
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:506 COLE RD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-4111
Mailing Address - Country:US
Mailing Address - Phone:734-241-7537
Mailing Address - Fax:
Practice Address - Street 1:2861 WEST RD.
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-2400
Practice Address - Country:US
Practice Address - Phone:734-675-2262
Practice Address - Fax:734-675-3430
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501002789225100000X
MI5501012324225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM93060004Medicare ID - Type UnspecifiedSECOND PROVIDER
MIM93060001Medicare ID - Type Unspecified
MI0M93060Medicare ID - Type UnspecifiedGROUP