Provider Demographics
NPI:1790837110
Name:RASCH, BRADLEY G (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:RASCH
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 650
Mailing Address - Street 2:
Mailing Address - City:CLOUDCROFT
Mailing Address - State:NM
Mailing Address - Zip Code:88317-0650
Mailing Address - Country:US
Mailing Address - Phone:505-682-2283
Mailing Address - Fax:505-682-2299
Practice Address - Street 1:62 CURLEW PL
Practice Address - Street 2:
Practice Address - City:CLOUDCROFT
Practice Address - State:NM
Practice Address - Zip Code:88317-0650
Practice Address - Country:US
Practice Address - Phone:505-682-2283
Practice Address - Fax:505-682-2299
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2010-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1417111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM00K142OtherBLUE CROSS BLUE SHIELD
NM00K142OtherBLUE CROSS BLUE SHIELD