Healthcare Provider Details

I. General information

NPI: 1013469113
Provider Name (Legal Business Name): BRUCE JORDAN FELLOWS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/16/2020
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

940 BELMONT ST RM C-208
BROCKTON MA
02301-5596
US

IV. Provider business mailing address

940 BELMONT ST RM C-208
BROCKTON MA
02301-5596
US

V. Phone/Fax

Practice location:
  • Phone: 203-838-9795
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number002036
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: