Provider Demographics
NPI:1982757357
Name:ELLINGSON, BRUCE PAUL (DC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:PAUL
Last Name:ELLINGSON
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 1:140 3RD ST N
Mailing Address - Street 2:
Mailing Address - City:WAITE PARK
Mailing Address - State:MN
Mailing Address - Zip Code:56387-1206
Mailing Address - Country:US
Mailing Address - Phone:320-251-3828
Mailing Address - Fax:320-258-4481
Practice Address - Street 1:140 3RD ST N
Practice Address - Street 2:
Practice Address - City:WAITE PARK
Practice Address - State:MN
Practice Address - Zip Code:56387-1206
Practice Address - Country:US
Practice Address - Phone:320-251-3828
Practice Address - Fax:320-258-4481
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2703111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor