Provider Demographics
NPI:1497896294
Name:CUPP, BRUCE FREDERICK (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:FREDERICK
Last Name:CUPP
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 1:4824 N MAIN ST
Mailing Address - Street 2:P.O. BOX 133
Mailing Address - City:EMINENCE
Mailing Address - State:KY
Mailing Address - Zip Code:40019-1018
Mailing Address - Country:US
Mailing Address - Phone:502-845-5482
Mailing Address - Fax:502-845-5149
Practice Address - Street 1:4824 N MAIN ST
Practice Address - Street 2:
Practice Address - City:EMINENCE
Practice Address - State:KY
Practice Address - Zip Code:40019-1018
Practice Address - Country:US
Practice Address - Phone:502-845-5482
Practice Address - Fax:502-845-5149
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2014-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH4096111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100149320Medicaid
KY6059001Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER
KY7100149320Medicaid