Provider Demographics
NPI:1770829814
Name:CARROLL, BRAD GLENN (DC)
Entity Type:Individual
Prefix:
First Name:BRAD
Middle Name:GLENN
Last Name:CARROLL
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 1:212 WALNUT CIR
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75766-0560
Mailing Address - Country:US
Mailing Address - Phone:469-576-2664
Mailing Address - Fax:903-586-6404
Practice Address - Street 1:2045 S JACKSON ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:TX
Practice Address - Zip Code:75766-5821
Practice Address - Country:US
Practice Address - Phone:903-586-3667
Practice Address - Fax:903-586-6404
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX5324111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor