Provider Demographics
NPI:1831163088
Name:EWOLDT, BRUCE A
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:EWOLDT
Suffix:
Gender:M
Credentials:
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 808
Mailing Address - Street 2:
Mailing Address - City:HULL
Mailing Address - State:IA
Mailing Address - Zip Code:51239-0808
Mailing Address - Country:US
Mailing Address - Phone:712-439-2936
Mailing Address - Fax:
Practice Address - Street 1:1134 MAIN ST.
Practice Address - Street 2:PO BOX 808
Practice Address - City:HULL
Practice Address - State:IA
Practice Address - Zip Code:51239
Practice Address - Country:US
Practice Address - Phone:712-439-2936
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-15
Last Update Date:2019-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA5116111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0231944Medicaid
IA23194Medicare PIN