Provider Demographics
NPI:1598915241
Name:SHEPHERD, BRADLEY MARK (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:MARK
Last Name:SHEPHERD
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 1:731 WINDMILL DR
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88011-8042
Mailing Address - Country:US
Mailing Address - Phone:801-833-9662
Mailing Address - Fax:
Practice Address - Street 1:205 BOUTZ ROAD
Practice Address - Street 2:BUILDING 4 SUITE 2
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005
Practice Address - Country:US
Practice Address - Phone:575-915-1550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX14070111N00000X
UT71183171202111N00000X
NM2107111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor