Provider Demographics
NPI:1083668297
Name:BRADSHAW CHIROPRACTIC
Entity Type:Organization
Organization Name:BRADSHAW CHIROPRACTIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:607-272-0186
Mailing Address - Street 1:309 N TIOGA ST
Mailing Address - Street 2:
Mailing Address - City:ITHACA
Mailing Address - State:NY
Mailing Address - Zip Code:14850-4239
Mailing Address - Country:US
Mailing Address - Phone:607-272-0186
Mailing Address - Fax:
Practice Address - Street 1:309 N TIOGA ST
Practice Address - Street 2:
Practice Address - City:ITHACA
Practice Address - State:NY
Practice Address - Zip Code:14850-4239
Practice Address - Country:US
Practice Address - Phone:607-272-0186
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY010839111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYBA 0569Medicare ID - Type Unspecified
NYV00888Medicare UPIN
RA 6882Medicare ID - Type Unspecified