Provider Demographics
NPI:1205010782
Name:BRADLEY FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:BRADLEY FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:319-447-1317
Mailing Address - Street 1:127 MARION BLVD STE B
Mailing Address - Street 2:
Mailing Address - City:MARION
Mailing Address - State:IA
Mailing Address - Zip Code:52302-3144
Mailing Address - Country:US
Mailing Address - Phone:319-447-1317
Mailing Address - Fax:319-447-1325
Practice Address - Street 1:127 MARION BLVD STE B
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IA
Practice Address - Zip Code:52302-3144
Practice Address - Country:US
Practice Address - Phone:319-447-1317
Practice Address - Fax:319-447-1325
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-20
Last Update Date:2007-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA06007111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1149021Medicaid
IA48468OtherBLUECROSS BLUESHIELD
IA48468Medicare PIN
IA48468OtherBLUECROSS BLUESHIELD