1972761757 NPI number — DR BRADLEY H YOUNG D C P A

Table of content: (NPI 1972761757)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972761757 NPI number — DR BRADLEY H YOUNG D C P A

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR BRADLEY H YOUNG D C P A
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
DR. BRAD YOUNG, CHIROPRACTOR
Provider Other Organization Name Type Code:
5
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972761757
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6 11TH AVENUE
Provider Second Line Business Mailing Address:
SUITE H-3
Provider Business Mailing Address City Name:
SHALIMAR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32579
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-613-2044
Provider Business Mailing Address Fax Number:
850-613-6593

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6 11TH AVENUE
Provider Second Line Business Practice Location Address:
SUITE H-3
Provider Business Practice Location Address City Name:
SHALIMAR
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32579
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-613-2044
Provider Business Practice Location Address Fax Number:
850-613-6593
Provider Enumeration Date:
05/28/2008

Additional Information

Authorized Official

Authorized Official Last Name:
YOUNG
Authorized Official First Name:
BRADLEY
Authorized Official Middle Name:
H
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
850-613-2044

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  CH8376 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 381515300 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1366538035 . This is a "INDIVIDUAL NPI" identifier . This identifiers is of the category "OTHER".




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