Provider Demographics
NPI:1801954318
Name:DWELLY, BRUCE E (DC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:E
Last Name:DWELLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:4944 SUNRISE BLVD
Mailing Address - Street 2:STE A
Mailing Address - City:FAIR OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:95628
Mailing Address - Country:US
Mailing Address - Phone:916-863-6288
Mailing Address - Fax:916-863-1144
Practice Address - Street 1:4944 SUNRISE BLVD
Practice Address - Street 2:STE A
Practice Address - City:FAIR OAKS
Practice Address - State:CA
Practice Address - Zip Code:95628
Practice Address - Country:US
Practice Address - Phone:916-863-6288
Practice Address - Fax:916-863-1144
Is Sole Proprietor?:No
Enumeration Date:2006-12-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA0201710111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor