Provider Demographics
NPI:1871698977
Name:COLEMAN, BRUCE ROBERT (DC)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ROBERT
Last Name:COLEMAN
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:PO BOX 156
Mailing Address - Street 2:
Mailing Address - City:YORKVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60560-0156
Mailing Address - Country:US
Mailing Address - Phone:630-553-7600
Mailing Address - Fax:
Practice Address - Street 1:129 COMMERCIAL DR UNIT 4
Practice Address - Street 2:
Practice Address - City:YORKVILLE
Practice Address - State:IL
Practice Address - Zip Code:60560-4731
Practice Address - Country:US
Practice Address - Phone:630-553-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-004818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL697160Medicare ID - Type Unspecified