Provider Demographics
NPI:1851021612
Name:BRUCE E. BLAKELY, D.C., A MEDICAL CORPORATION
Entity Type:Organization
Organization Name:BRUCE E. BLAKELY, D.C., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BRUCE BLAKELY, D.C.
Authorized Official - Prefix:
Authorized Official - First Name:BRUCE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKELY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-281-1999
Mailing Address - Street 1:PO BOX 1176
Mailing Address - Street 2:
Mailing Address - City:CARDIFF
Mailing Address - State:CA
Mailing Address - Zip Code:92007-7176
Mailing Address - Country:US
Mailing Address - Phone:858-509-7999
Mailing Address - Fax:
Practice Address - Street 1:2878 CAMINO DEL RIO S
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-3872
Practice Address - Country:US
Practice Address - Phone:619-281-1999
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty