Provider Demographics
NPI:1003384926
Name:BRUCKER, MIKAEL LAURSEN (LAC, ND)
Entity Type:Individual
Prefix:DR
First Name:MIKAEL
Middle Name:LAURSEN
Last Name:BRUCKER
Suffix:
Gender:M
Credentials:LAC, ND
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 MEETINGHOUSE RD
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1417
Mailing Address - Country:US
Mailing Address - Phone:215-919-1166
Mailing Address - Fax:
Practice Address - Street 1:710 MEETINGHOUSE RD
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027
Practice Address - Country:US
Practice Address - Phone:215-919-1166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-08
Last Update Date:2018-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT099.0134073175F00000X
PAAK001281171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No175F00000XOther Service ProvidersNaturopath