Provider Demographics
NPI:1477119741
Name:BUNGE, BRIAN (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:
Last Name:BUNGE
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 1:55 ALISON TRL
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-8932
Mailing Address - Country:US
Mailing Address - Phone:678-925-3874
Mailing Address - Fax:
Practice Address - Street 1:113 FAIRPLAY ST
Practice Address - Street 2:
Practice Address - City:RUTLEDGE
Practice Address - State:GA
Practice Address - Zip Code:30663-2377
Practice Address - Country:US
Practice Address - Phone:706-557-0211
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR010206111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor