Provider Demographics
NPI:1619095767
Name:BRADSHAW CHIROPRACTIC CENTER
Entity Type:Organization
Organization Name:BRADSHAW CHIROPRACTIC CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:WESLEY
Authorized Official - Middle Name:ALAN
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:432-333-2225
Mailing Address - Street 1:2626 JOHN BEN SHEPPERD PKWY
Mailing Address - Street 2:SUITE 100A
Mailing Address - City:ODESSA
Mailing Address - State:TX
Mailing Address - Zip Code:79761-1958
Mailing Address - Country:US
Mailing Address - Phone:432-333-2225
Mailing Address - Fax:432-333-2226
Practice Address - Street 1:2626 JOHN BEN SHEPPERD PKWY
Practice Address - Street 2:SUITE 100A
Practice Address - City:ODESSA
Practice Address - State:TX
Practice Address - Zip Code:79761-1958
Practice Address - Country:US
Practice Address - Phone:432-333-2225
Practice Address - Fax:432-333-2226
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2008-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6046111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX083470701Medicaid
TX00K35QMedicare PIN
TXU42228Medicare UPIN