Provider Demographics
NPI:1093919359
Name:DEVEREAUX, BRADLEY JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAY
Last Name:DEVEREAUX
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 1:190 W 100 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010-6205
Mailing Address - Country:US
Mailing Address - Phone:801-292-1111
Mailing Address - Fax:
Practice Address - Street 1:190 W 100 S
Practice Address - Street 2:SUITE A
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010-6205
Practice Address - Country:US
Practice Address - Phone:801-292-1111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT368851-1202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor