Provider Demographics
NPI:1669448478
Name:DETWILER, BRUCE L (DC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:L
Last Name:DETWILER
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 1:2848 W LIBERTY AVE
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15216-2620
Mailing Address - Country:US
Mailing Address - Phone:412-344-5055
Mailing Address - Fax:412-344-8088
Practice Address - Street 1:2848 W LIBERTY AVE
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15216-2620
Practice Address - Country:US
Practice Address - Phone:412-344-5055
Practice Address - Fax:412-344-8088
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC002372L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA196991OtherHIGHMARK
PAT30104Medicare UPIN
PA196991Medicare ID - Type Unspecified