Provider Demographics
NPI:1942546064
Name:DAVIS, BRADLEY A (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:A
Last Name:DAVIS
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 1:731 SABRINA DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:EAST PEORIA
Mailing Address - State:IL
Mailing Address - Zip Code:61611-3581
Mailing Address - Country:US
Mailing Address - Phone:309-699-7222
Mailing Address - Fax:
Practice Address - Street 1:731 SABRINA DR
Practice Address - Street 2:SUITE B
Practice Address - City:EAST PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61611-3581
Practice Address - Country:US
Practice Address - Phone:309-699-7222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2012-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.012215111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor