Provider Demographics
NPI:1669503421
Name:STEVENS, BRUCE DWIGHT (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:DWIGHT
Last Name:STEVENS
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 1:313 QUIET HILL LN
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-5535
Mailing Address - Country:US
Mailing Address - Phone:770-592-2505
Mailing Address - Fax:770-592-2433
Practice Address - Street 1:2453 TOWNE LAKE PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-5525
Practice Address - Country:US
Practice Address - Phone:770-592-2505
Practice Address - Fax:770-592-2433
Is Sole Proprietor?:No
Enumeration Date:2007-03-07
Last Update Date:2020-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23697111N00000X
GACHIR005186111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7186428Medicaid
CADC0236970Medicaid
ZZZ59082YOtherBLUE SHIELD OF CALIFORNIA
CACW451AMedicare PIN