Provider Demographics
NPI:1023015153
Name:BRADFORD, JUSTINE ELOISE (DC)
Entity Type:Individual
Prefix:DR
First Name:JUSTINE
Middle Name:ELOISE
Last Name:BRADFORD
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:PO BOX 2246
Mailing Address - Street 2:
Mailing Address - City:STATELINE
Mailing Address - State:NV
Mailing Address - Zip Code:89449-2246
Mailing Address - Country:US
Mailing Address - Phone:775-588-0921
Mailing Address - Fax:775-588-0924
Practice Address - Street 1:276 KINGSBURY GRADE
Practice Address - Street 2:STE 1050
Practice Address - City:STATELINE
Practice Address - State:NV
Practice Address - Zip Code:89449-2246
Practice Address - Country:US
Practice Address - Phone:775-588-0921
Practice Address - Fax:775-588-0924
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVB444111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVDC444Medicare ID - Type Unspecified
NVU45985Medicare UPIN