Provider Demographics
NPI:1104939552
Name:BRUECKMANN, MICHAEL PHILLIP (LMT, NCTMB)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:PHILLIP
Last Name:BRUECKMANN
Suffix:
Gender:M
Credentials:LMT, NCTMB
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1344 STONE CREEK VALLEY CIR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63366-3391
Mailing Address - Country:US
Mailing Address - Phone:636-795-1758
Mailing Address - Fax:
Practice Address - Street 1:1344 STONE CREEK VALLEY CIR
Practice Address - Street 2:
Practice Address - City:O FALLON
Practice Address - State:MO
Practice Address - Zip Code:63366-3391
Practice Address - Country:US
Practice Address - Phone:636-795-1758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001025527174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist