Provider Demographics
NPI:1639587942
Name:BRADLEY, SAMANTHA ELIZABETH (DC)
Entity Type:Individual
Prefix:DR
First Name:SAMANTHA
Middle Name:ELIZABETH
Last Name:BRADLEY
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:SAMANTHA
Other - Middle Name:ELIZABETH
Other - Last Name:RACZKOWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DC
Mailing Address - Street 1:8115 FRUIT FARM RD
Mailing Address - Street 2:
Mailing Address - City:BELVIDERE
Mailing Address - State:IL
Mailing Address - Zip Code:61008-9075
Mailing Address - Country:US
Mailing Address - Phone:815-547-6333
Mailing Address - Fax:815-642-5695
Practice Address - Street 1:8115 FRUIT FARM RD
Practice Address - Street 2:
Practice Address - City:BELVIDERE
Practice Address - State:IL
Practice Address - Zip Code:61008-9075
Practice Address - Country:US
Practice Address - Phone:815-547-6333
Practice Address - Fax:815-642-5695
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-30
Last Update Date:2019-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038012666111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL5090934OtherAETNA PROVIDER ID