Healthcare Provider Details

I. General information

NPI: 1568503704
Provider Name (Legal Business Name): CUPP CHIROPRACTIC CENTER, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/09/2007
Last Update Date: 04/21/2014
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 PO 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 StateKY

VIII. Authorized Official

Name: DR. BRUCE FREDERICK CUPP
Title or Position: PRESIDENT
Credential: D.C.
Phone: 502-845-5482