Provider Demographics
NPI:1871585695
Name:HUMPHRIES, BRUCE ALLEN (DC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALLEN
Last Name:HUMPHRIES
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 1:1399 W. COLTON AVE.
Mailing Address - Street 2:SUITE #9
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92374-4536
Mailing Address - Country:US
Mailing Address - Phone:909-793-9787
Mailing Address - Fax:909-793-9891
Practice Address - Street 1:1399 W. COLTON AVE.
Practice Address - Street 2:SUITE #9
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92374-4536
Practice Address - Country:US
Practice Address - Phone:909-793-9787
Practice Address - Fax:909-793-9891
Is Sole Proprietor?:No
Enumeration Date:2005-08-17
Last Update Date:2010-07-08
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-29
Provider Licenses
StateLicense IDTaxonomies
CA20633111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABZ193AMedicare UPIN
CADC0206330Medicare UPIN