Provider Demographics
NPI:1003999095
Name:BLAKELY, BRUCE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:
Last Name:BLAKELY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3570 CAMINO DEL RIO N
Mailing Address - Street 2:STE. 104
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1747
Mailing Address - Country:US
Mailing Address - Phone:619-281-1999
Mailing Address - Fax:619-281-5357
Practice Address - Street 1:2878 CAMINO DEL RIO S STE 120
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3844
Practice Address - Country:US
Practice Address - Phone:619-281-1999
Practice Address - Fax:619-281-5357
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2019-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13741111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor