Provider Demographics
NPI:1003970484
Name:BRAGG, TINA (DC)
Entity Type:Individual
Prefix:DR
First Name:TINA
Middle Name:
Last Name:BRAGG
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1970 DOMINION WAY
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80918-1465
Mailing Address - Country:US
Mailing Address - Phone:719-574-5240
Mailing Address - Fax:719-599-8044
Practice Address - Street 1:1970 DOMINION WAY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80918-1465
Practice Address - Country:US
Practice Address - Phone:719-574-5240
Practice Address - Fax:719-599-8044
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-20
Last Update Date:2008-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO5156111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
COC448928Medicare PIN