Provider Demographics
NPI:1851884191
Name:PHILPOTT, BRUCE M
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:M
Last Name:PHILPOTT
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:BRUCE
Other - Middle Name:M
Other - Last Name:PHILPOTT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:3543 BURLINGAME AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49509-3399
Mailing Address - Country:US
Mailing Address - Phone:616-328-4601
Mailing Address - Fax:
Practice Address - Street 1:3543 BURLINGAME AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49509-3399
Practice Address - Country:US
Practice Address - Phone:616-328-4601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-06-12
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501010771225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist