Healthcare Provider Details

I. General information

NPI: 1629174222
Provider Name (Legal Business Name): BERNARD P. BUBANIC DC DACBSP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 11/18/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4082 FULTON DRIVE NW
CANTON OH
44718
US

IV. Provider business mailing address

4082 FULTON DRIVE NW
CANTON OH
44718
US

V. Phone/Fax

Practice location:
  • Phone: 330-491-8100
  • Fax: 844-572-2173
Mailing address:
  • Phone: 330-491-8100
  • Fax: 844-572-2173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number1307
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: