Provider Demographics
NPI:1407921570
Name:WEBER, BRUCE W (DC, CSCS)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:W
Last Name:WEBER
Suffix:
Gender:M
Credentials:DC, CSCS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7124 COMMONS DR
Mailing Address - Street 2:SUITE D
Mailing Address - City:CHEYENNE
Mailing Address - State:WY
Mailing Address - Zip Code:82009-2620
Mailing Address - Country:US
Mailing Address - Phone:307-635-6777
Mailing Address - Fax:307-635-6780
Practice Address - Street 1:7124 COMMONS DR
Practice Address - Street 2:SUITE D
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82009-2620
Practice Address - Country:US
Practice Address - Phone:307-635-6777
Practice Address - Fax:307-635-6780
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-22
Last Update Date:2016-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY11638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY1407921570Medicaid
WYV00335Medicare UPIN
WYW22118Medicare PIN