Provider Demographics
NPI:1801582952
Name:BRUCKNER, SIMON (DC)
Entity type:Individual
Prefix:
First Name:SIMON
Middle Name:
Last Name:BRUCKNER
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 1:2625 BUTTERFIELD RD STE 301N
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-1266
Mailing Address - Country:US
Mailing Address - Phone:630-468-1824
Mailing Address - Fax:
Practice Address - Street 1:9123 SE SAINT HELENS ST STE 185
Practice Address - Street 2:
Practice Address - City:CLACKAMAS
Practice Address - State:OR
Practice Address - Zip Code:97015-6800
Practice Address - Country:US
Practice Address - Phone:503-206-5042
Practice Address - Fax:503-206-5751
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2024-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR6288111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor