Healthcare Provider Details

I. General information

NPI: 1669503421
Provider Name (Legal Business Name): BRUCE DWIGHT STEVENS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/07/2007
Last Update Date: 05/18/2020
Certification Date: 05/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2453 TOWNE LAKE PKWY
WOODSTOCK GA
30189-5525
US

IV. Provider business mailing address

313 QUIET HILL LN
WOODSTOCK GA
30189-5535
US

V. Phone/Fax

Practice location:
  • Phone: 770-592-2505
  • Fax: 770-592-2433
Mailing address:
  • Phone: 770-592-2505
  • Fax: 770-592-2433

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number23697
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCHIR005186
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: