Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 1604012 | WI |
NPI | 1003914821 |
---|---|
Provider Name | David Bruce Bakke |
First Address | Deforest, WI 53532 |
Second Address | Deforest, WI 53532 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
38765400 | (05) | WI |
39125337055 | BLUE CROSS BLUE SHIELD (01) | WI |
T61406 | (02) |