Provider Demographics
NPI:1083615546
Name:WARDER, BRUCE ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:ALLEN
Last Name:WARDER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19231 VICTORY BLVD
Mailing Address - Street 2:SUITE 556
Mailing Address - City:RESEDA
Mailing Address - State:CA
Mailing Address - Zip Code:91335-6308
Mailing Address - Country:US
Mailing Address - Phone:818-705-4964
Mailing Address - Fax:818-705-8619
Practice Address - Street 1:19231 VICTORY BLVD
Practice Address - Street 2:SUITE 556
Practice Address - City:RESEDA
Practice Address - State:CA
Practice Address - Zip Code:91335-6308
Practice Address - Country:US
Practice Address - Phone:818-705-4964
Practice Address - Fax:818-705-8619
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-09
Last Update Date:2012-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC23706111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU56963Medicare UPIN