Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111N00000X | Chiropractor | 13741 | CA |
NPI | 1003999095 |
---|---|
Provider Name | Dr. Bruce Blakely |
First Address | San Diego, CA 92108-1747 |
Second Address | San Diego, CA 92108-3844 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 23/10/2006 |
Last Update Date | 07/02/2019 |