Provider Demographics
NPI:1992888531
Name:LANGEVIN, BRUCE ALAN
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ALAN
Last Name:LANGEVIN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9518
Mailing Address - Street 2:
Mailing Address - City:BOLTON
Mailing Address - State:CT
Mailing Address - Zip Code:06043-9518
Mailing Address - Country:US
Mailing Address - Phone:860-646-8758
Mailing Address - Fax:860-646-0256
Practice Address - Street 1:921 BOSTON TURNPIKE
Practice Address - Street 2:
Practice Address - City:BOLTON
Practice Address - State:CT
Practice Address - Zip Code:06043
Practice Address - Country:US
Practice Address - Phone:860-646-8758
Practice Address - Fax:860-646-0256
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0055322251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT080005532CT08OtherBCBS
CT44901OtherORTHONET