Healthcare Provider Details

I. General information

NPI: 1497896294
Provider Name (Legal Business Name): BRUCE FREDERICK CUPP D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 04/08/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4824 N MAIN ST
EMINENCE KY
40019-1018
US

IV. Provider business mailing address

4824 N MAIN ST P.O. BOX 133
EMINENCE KY
40019-1018
US

V. Phone/Fax

Practice location:
  • Phone: 502-845-5482
  • Fax: 502-845-5149
Mailing address:
  • Phone: 502-845-5482
  • Fax: 502-845-5149

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4096
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: