Provider Demographics
NPI:1700211489
Name:BRADLEY CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:BRADLEY CHIROPRACTIC CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:870-378-5689
Mailing Address - Street 1:2085 LLOYD WILLIAMS RD
Mailing Address - Street 2:
Mailing Address - City:IMBODEN
Mailing Address - State:AR
Mailing Address - Zip Code:72434-9456
Mailing Address - Country:US
Mailing Address - Phone:870-378-5689
Mailing Address - Fax:
Practice Address - Street 1:301 N MISSOURI AVE
Practice Address - Street 2:SUITE 17
Practice Address - City:CORNING
Practice Address - State:AR
Practice Address - Zip Code:72422-1600
Practice Address - Country:US
Practice Address - Phone:870-378-5689
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR16025111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty