Provider Demographics
NPI:1003969460
Name:BRADLEY A. TACK P.S.C.
Entity Type:Organization
Organization Name:BRADLEY A. TACK P.S.C.
Other - Org Name:CALVERT CITY CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:270-395-4540
Mailing Address - Street 1:5131 US HIGHWAY 62
Mailing Address - Street 2:
Mailing Address - City:CALVERT CITY
Mailing Address - State:KY
Mailing Address - Zip Code:42029-8390
Mailing Address - Country:US
Mailing Address - Phone:270-395-4540
Mailing Address - Fax:270-395-7715
Practice Address - Street 1:5131 US HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029-8390
Practice Address - Country:US
Practice Address - Phone:270-395-4540
Practice Address - Fax:270-395-7715
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85900181Medicaid
KY85900181Medicaid