Provider Demographics
NPI:1790700979
Name:BELLUCCI, MARK ROBERT (DC)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:BELLUCCI
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 1:155 HAZARD AVE
Mailing Address - Street 2:
Mailing Address - City:ENFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06082-4580
Mailing Address - Country:US
Mailing Address - Phone:860-763-4848
Mailing Address - Fax:860-763-4850
Practice Address - Street 1:155 HAZARD AVE
Practice Address - Street 2:
Practice Address - City:ENFIELD
Practice Address - State:CT
Practice Address - Zip Code:06082-4580
Practice Address - Country:US
Practice Address - Phone:860-763-4848
Practice Address - Fax:860-763-4850
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-12
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT000701111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
DET22833Medicare UPIN
CT3500000610Medicare ID - Type Unspecified