Provider Demographics
NPI:1578658514
Name:BRADHAM CHIROPRACTIC CLINIC, PA
Entity Type:Organization
Organization Name:BRADHAM CHIROPRACTIC CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADHAM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:910-892-1119
Mailing Address - Street 1:PO BOX 506
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-0506
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:407-K EAST JACKSON BLVD.
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-9628
Practice Address - Country:US
Practice Address - Phone:910-892-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-04
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2481111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8902671Medicaid
NC2452359Medicare ID - Type Unspecified