Provider Demographics
NPI:1023024759
Name:WALTERS, BRADLEY DARIN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DARIN
Last Name:WALTERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 COORS BLVD NW STE A7
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87120-2794
Mailing Address - Country:US
Mailing Address - Phone:505-899-0708
Mailing Address - Fax:505-899-0707
Practice Address - Street 1:6200 COORS BLVD NW STE A7
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87120-2794
Practice Address - Country:US
Practice Address - Phone:505-899-0708
Practice Address - Fax:505-899-0707
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMU63982Medicare UPIN