Provider Demographics
NPI:1518467828
Name:BRUECKNER, TRAVIS JAMES
Entity Type:Individual
Prefix:MR
First Name:TRAVIS
Middle Name:JAMES
Last Name:BRUECKNER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:921 LAWLESS ST NE
Mailing Address - Street 2:
Mailing Address - City:KEIZER
Mailing Address - State:OR
Mailing Address - Zip Code:97303-4667
Mailing Address - Country:US
Mailing Address - Phone:503-507-7274
Mailing Address - Fax:
Practice Address - Street 1:921 LAWLESS ST NE
Practice Address - Street 2:
Practice Address - City:KEIZER
Practice Address - State:OR
Practice Address - Zip Code:97303-4667
Practice Address - Country:US
Practice Address - Phone:503-507-7274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC186260171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist