1699964478 NPI number — BRADLEY CHIROPRACTIC LLC

Table of content: (NPI 1699964478)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699964478 NPI number — BRADLEY CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRADLEY CHIROPRACTIC LLC
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:
Provider Other Organization Name Type Code:
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:
1699964478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/06/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
11/16/2022
NPI Reactivation Date:
12/06/2022

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1761 JEFFCO BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARNOLD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63010-2713
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
636-296-1222
Provider Business Mailing Address Fax Number:
636-296-1226

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1761 JEFFCO BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARNOLD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63010-2713
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
636-296-1222
Provider Business Practice Location Address Fax Number:
636-296-1226
Provider Enumeration Date:
10/17/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BRADLEY
Authorized Official First Name:
SHAWN
Authorized Official Middle Name:
P
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
636-296-1222

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2004018211 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: DG7614 . This is a "RAILROAD GROUP PIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 192584 . This is a "BLUE CROSS GROUP PIN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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