Provider Demographics
NPI:1720124761
Name:NIELSON, BRUCE C (DC)
Entity Type:Individual
Prefix:DR
First Name:BRUCE
Middle Name:C
Last Name:NIELSON
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 1:7400 UNION PARK AVE STE 301
Mailing Address - Street 2:
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-6707
Mailing Address - Country:US
Mailing Address - Phone:801-568-1598
Mailing Address - Fax:801-568-1594
Practice Address - Street 1:7400 UNION PARK AVE STE 301
Practice Address - Street 2:
Practice Address - City:MIDVALE
Practice Address - State:UT
Practice Address - Zip Code:84047-6707
Practice Address - Country:US
Practice Address - Phone:801-568-1598
Practice Address - Fax:801-568-1594
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT983650451202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTU71753Medicare UPIN