Provider Demographics
NPI:1578712949
Name:BRAD EGBERT CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:BRAD EGBERT CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:EGBERT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-356-8818
Mailing Address - Street 1:1134 BOND AVE
Mailing Address - Street 2:
Mailing Address - City:REXBURG
Mailing Address - State:ID
Mailing Address - Zip Code:83440-3582
Mailing Address - Country:US
Mailing Address - Phone:208-356-8818
Mailing Address - Fax:208-356-0458
Practice Address - Street 1:1134 BOND AVE
Practice Address - Street 2:
Practice Address - City:REXBURG
Practice Address - State:ID
Practice Address - Zip Code:83440-3582
Practice Address - Country:US
Practice Address - Phone:208-356-8818
Practice Address - Fax:208-356-0458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-10
Last Update Date:2008-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA543111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1134279565OtherPERSONAL NPI NUMBER