Provider Demographics
NPI:1578616587
Name:MCNULTY, BRAD JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRAD
Middle Name:JOHN
Last Name:MCNULTY
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 1:4114 MILL ST NE
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:GA
Mailing Address - Zip Code:30014-2539
Mailing Address - Country:US
Mailing Address - Phone:770-787-6113
Mailing Address - Fax:770-787-8287
Practice Address - Street 1:4114 MILL ST NE
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:GA
Practice Address - Zip Code:30014-2539
Practice Address - Country:US
Practice Address - Phone:770-787-6113
Practice Address - Fax:770-787-8287
Is Sole Proprietor?:No
Enumeration Date:2007-01-21
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR005076111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCDVJMedicare UPIN