Provider Demographics
NPI:1952453250
Name:BRUCE, SCOTT RANDAL (DC)
Entity Type:Individual
Prefix:
First Name:SCOTT
Middle Name:RANDAL
Last Name:BRUCE
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:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:ST MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-0308
Mailing Address - Country:US
Mailing Address - Phone:419-394-8194
Mailing Address - Fax:419-394-4783
Practice Address - Street 1:1633 CELINA RD
Practice Address - Street 2:
Practice Address - City:ST MARYS
Practice Address - State:OH
Practice Address - Zip Code:45885-1215
Practice Address - Country:US
Practice Address - Phone:419-394-8194
Practice Address - Fax:419-394-4783
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1393111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0868744Medicaid
OHBR0655222Medicare ID - Type Unspecified
T90002Medicare UPIN