Provider Demographics
NPI:1275706954
Name:FACKRELL, BRAD (DC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:
Last Name:FACKRELL
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 1:3301 SOUTHERN BLVD SE
Mailing Address - Street 2:SUITE 304
Mailing Address - City:RIO RANCHO
Mailing Address - State:NM
Mailing Address - Zip Code:87124-2085
Mailing Address - Country:US
Mailing Address - Phone:505-891-2280
Mailing Address - Fax:
Practice Address - Street 1:3301 SOUTHERN BLVD SE
Practice Address - Street 2:SUITE 304
Practice Address - City:RIO RANCHO
Practice Address - State:NM
Practice Address - Zip Code:87124-2085
Practice Address - Country:US
Practice Address - Phone:505-891-2280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-02
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1577111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM343430900Medicare PIN