Provider Demographics
NPI:1609971241
Name:BRADLEY, KEVIN G (CH)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:G
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:CH
Other - Prefix:
Other - First Name:KEVIN
Other - Middle Name:GARNER
Other - Last Name:BRADLEY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DC
Mailing Address - Street 1:PO BOX 930
Mailing Address - Street 2:640 ALEXANDER SUITE 107
Mailing Address - City:EUFAULA
Mailing Address - State:OK
Mailing Address - Zip Code:74432-0930
Mailing Address - Country:US
Mailing Address - Phone:918-689-2424
Mailing Address - Fax:918-618-4778
Practice Address - Street 1:640 ALEXANDER DR STE 107
Practice Address - Street 2:
Practice Address - City:EUFAULA
Practice Address - State:OK
Practice Address - Zip Code:74432-4013
Practice Address - Country:US
Practice Address - Phone:918-689-2424
Practice Address - Fax:918-618-4778
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2008-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3321111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKU65232Medicare UPIN