Provider Demographics
NPI:1326024464
Name:BOTTCHER, BRUCE A (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:A
Last Name:BOTTCHER
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:PO BOX 463
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TX
Mailing Address - Zip Code:78636-0463
Mailing Address - Country:US
Mailing Address - Phone:830-868-4280
Mailing Address - Fax:
Practice Address - Street 1:405 S US HIGHWAY 281
Practice Address - Street 2:SUITE 101-C
Practice Address - City:JOHNSON CITY
Practice Address - State:TX
Practice Address - Zip Code:78636-4950
Practice Address - Country:US
Practice Address - Phone:830-868-4280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2014-12-16
Deactivation Date:2010-07-02
Deactivation Code:
Reactivation Date:2014-02-12
Provider Licenses
StateLicense IDTaxonomies
TX7263111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605723Medicare PIN
TXU66999Medicare UPIN
TX350050944Medicare PIN