Provider Demographics
NPI:1467615815
Name:WALTER, BRADLEY JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JOHN
Last Name:WALTER
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 1:2013 OLDE REGENT WAY
Mailing Address - Street 2:
Mailing Address - City:LELAND
Mailing Address - State:NC
Mailing Address - Zip Code:28451-4193
Mailing Address - Country:US
Mailing Address - Phone:910-371-2212
Mailing Address - Fax:910-371-2231
Practice Address - Street 1:2013 OLDE REGENT WAY STE 130
Practice Address - Street 2:
Practice Address - City:LELAND
Practice Address - State:NC
Practice Address - Zip Code:28451-7285
Practice Address - Country:US
Practice Address - Phone:910-371-2212
Practice Address - Fax:910-371-2231
Is Sole Proprietor?:No
Enumeration Date:2008-07-07
Last Update Date:2012-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE1521111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor