Provider Demographics
NPI:1346648359
Name:WELLINGTON, BRUCE BURR
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:BURR
Last Name:WELLINGTON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BURR
Other - Middle Name:
Other - Last Name:WELLINGTON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:100 DEBARTOLO PL STE 220
Mailing Address - Street 2:
Mailing Address - City:YOUNGSTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44512-6095
Mailing Address - Country:US
Mailing Address - Phone:330-965-7828
Mailing Address - Fax:330-965-7901
Practice Address - Street 1:8301 TALLMADGE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9231
Practice Address - Country:US
Practice Address - Phone:330-219-2891
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-08
Last Update Date:2015-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH009674225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist