Provider Demographics
NPI:1053506857
Name:BRADDOCK CHIROPRACTIC AND FAMILY WELLNESS
Entity Type:Organization
Organization Name:BRADDOCK CHIROPRACTIC AND FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-482-1234
Mailing Address - Street 1:PO BOX 1782
Mailing Address - Street 2:
Mailing Address - City:VAN ALSTYNE
Mailing Address - State:TX
Mailing Address - Zip Code:75495-1782
Mailing Address - Country:US
Mailing Address - Phone:903-482-1234
Mailing Address - Fax:903-482-1232
Practice Address - Street 1:119 N. MAIN ST.
Practice Address - Street 2:
Practice Address - City:VAN ALSTYNE
Practice Address - State:TX
Practice Address - Zip Code:75495
Practice Address - Country:US
Practice Address - Phone:903-482-1234
Practice Address - Fax:903-482-1232
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-14
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8X8450OtherBLUE CROSS BLUE SHIELD
TX612233Medicare PIN
TX8X8450OtherBLUE CROSS BLUE SHIELD