Provider Demographics
NPI:1013981356
Name:VANDYKE, BRADLEY DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DEAN
Last Name:VANDYKE
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 855
Mailing Address - Street 2:
Mailing Address - City:VANSANT
Mailing Address - State:VA
Mailing Address - Zip Code:24656-0855
Mailing Address - Country:US
Mailing Address - Phone:276-597-8387
Mailing Address - Fax:276-597-2154
Practice Address - Street 1:1779 LOVERS GAP ROAD
Practice Address - Street 2:
Practice Address - City:VANSANT
Practice Address - State:VA
Practice Address - Zip Code:24656
Practice Address - Country:US
Practice Address - Phone:276-597-8387
Practice Address - Fax:276-597-2154
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-14
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001184111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV7600037000Medicaid
WV7600037000Medicaid