Provider Demographics
NPI:1972620789
Name:BLUCKER, JOHN M (DC)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:BLUCKER
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9211 ARCHIBALD AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-5207
Mailing Address - Country:US
Mailing Address - Phone:909-980-4954
Mailing Address - Fax:909-980-2455
Practice Address - Street 1:9211 ARCHIBALD AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-5207
Practice Address - Country:US
Practice Address - Phone:909-980-4954
Practice Address - Fax:909-980-2455
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-25
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13459111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAT05030Medicare UPIN
CADC013459Medicare ID - Type UnspecifiedMEDICARE ID