Provider Demographics
NPI:1386045706
Name:BRILLIANTINE, BRUCE R (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:R
Last Name:BRILLIANTINE
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:P.O. BOX 352
Mailing Address - Street 2:
Mailing Address - City:CROSSWICKS
Mailing Address - State:NJ
Mailing Address - Zip Code:08515-9685
Mailing Address - Country:US
Mailing Address - Phone:609-883-2222
Mailing Address - Fax:609-324-9400
Practice Address - Street 1:2 PRINCESS ROAD
Practice Address - Street 2:SUIET #2
Practice Address - City:LAWRENCEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08648
Practice Address - Country:US
Practice Address - Phone:609-883-2222
Practice Address - Fax:609-324-9400
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-05
Last Update Date:2014-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00173600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor