Provider Demographics
NPI:1144622184
Name:BRADLEY CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:BRADLEY CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:DARRYL
Authorized Official - Middle Name:LIONEL
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:314-371-2225
Mailing Address - Street 1:330 N VANDEVENTER AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3104
Mailing Address - Country:US
Mailing Address - Phone:314-371-2225
Mailing Address - Fax:314-533-2404
Practice Address - Street 1:330 N VANDEVENTER AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3104
Practice Address - Country:US
Practice Address - Phone:314-371-2225
Practice Address - Fax:314-533-2404
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-09-22
Last Update Date:2014-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2001010035111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty