Provider Demographics
NPI:1114193638
Name:BRADDOCK CHIROPRACTIC & FAMILY WELLNESS
Entity Type:Organization
Organization Name:BRADDOCK CHIROPRACTIC & FAMILY WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:CALEB
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADDOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
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:
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:75495-1782
Practice Address - Country:US
Practice Address - Phone:903-482-1232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-05
Last Update Date:2008-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX10170111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0068PLOtherBCBS
TX00Z532Medicare PIN