Provider Demographics
NPI:1689646416
Name:BURT, BRADLEY SHANE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:SHANE
Last Name:BURT
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:PO BOX 790
Mailing Address - Street 2:
Mailing Address - City:WALCOTT
Mailing Address - State:IA
Mailing Address - Zip Code:52773-0790
Mailing Address - Country:US
Mailing Address - Phone:563-284-6927
Mailing Address - Fax:563-284-6927
Practice Address - Street 1:790 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WALCOTT
Practice Address - State:IA
Practice Address - Zip Code:52773-9505
Practice Address - Country:US
Practice Address - Phone:563-284-6927
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA06487111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
I5974Medicare ID - Type Unspecified
IAU89608Medicare UPIN