Provider Demographics
NPI:1821159757
Name:DOBRY ETHERTON, BAMBI
Entity Type:Individual
Prefix:
First Name:BAMBI
Middle Name:
Last Name:DOBRY ETHERTON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MURRAY
Mailing Address - State:KY
Mailing Address - Zip Code:42071-1962
Mailing Address - Country:US
Mailing Address - Phone:270-759-0030
Mailing Address - Fax:270-767-0471
Practice Address - Street 1:1103 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MURRAY
Practice Address - State:KY
Practice Address - Zip Code:42071-1962
Practice Address - Country:US
Practice Address - Phone:270-759-0030
Practice Address - Fax:270-767-0471
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2011-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
U97789Medicare UPIN
0795901Medicare ID - Type Unspecified