Provider Demographics
NPI:1174680482
Name:DR. BRAD PARK PLLC
Entity Type:Organization
Organization Name:DR. BRAD PARK PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:580-928-3125
Mailing Address - Street 1:PO BOX 7
Mailing Address - Street 2:
Mailing Address - City:SAYRE
Mailing Address - State:OK
Mailing Address - Zip Code:73662-0007
Mailing Address - Country:US
Mailing Address - Phone:580-928-3125
Mailing Address - Fax:580-928-3605
Practice Address - Street 1:307 N.E. HWY 66
Practice Address - Street 2:
Practice Address - City:SAYRE
Practice Address - State:OK
Practice Address - Zip Code:73662
Practice Address - Country:US
Practice Address - Phone:580-928-3125
Practice Address - Fax:580-928-3605
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1638111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK=========OtherTAX ID
OK=========OtherTAX ID