Provider Demographics
NPI:1386645737
Name:TACK, BRADLEY A (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:A
Last Name:TACK
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 1:330 OAK SHADOW LN
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:KY
Mailing Address - Zip Code:42025-5494
Mailing Address - Country:US
Mailing Address - Phone:270-527-8216
Mailing Address - Fax:
Practice Address - Street 1:5131 US HIGHWAY 62
Practice Address - Street 2:
Practice Address - City:CALVERT CITY
Practice Address - State:KY
Practice Address - Zip Code:42029-8390
Practice Address - Country:US
Practice Address - Phone:270-395-4540
Practice Address - Fax:270-395-7715
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY3500051847OtherRRMEDICARE
KY85000685Medicaid
KY0673101Medicare ID - Type UnspecifiedMEDICARE
KY85000685Medicaid