Provider Demographics
NPI:1659621811
Name:BRADLEY A HEIMER, LLC
Entity Type:Organization
Organization Name:BRADLEY A HEIMER, LLC
Other - Org Name:580 SPORTS MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING/BILLING MGR
Authorized Official - Prefix:
Authorized Official - First Name:BETTI
Authorized Official - Middle Name:R
Authorized Official - Last Name:ESTEP
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-521-1969
Mailing Address - Street 1:PO BOX 269031
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-9031
Mailing Address - Country:US
Mailing Address - Phone:405-521-1969
Mailing Address - Fax:405-521-1979
Practice Address - Street 1:1201 ARLINGTON ST STE A
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-4072
Practice Address - Country:US
Practice Address - Phone:580-436-7173
Practice Address - Fax:580-436-7176
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4081111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty