Provider Demographics
NPI:1023106069
Name:FORTUNE, BRADLEY GARTH (DC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:GARTH
Last Name:FORTUNE
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 1:4204 AUSTIN AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNWOOD
Mailing Address - State:TX
Mailing Address - Zip Code:76801-6822
Mailing Address - Country:US
Mailing Address - Phone:325-641-8800
Mailing Address - Fax:
Practice Address - Street 1:4204 AUSTIN AVE
Practice Address - Street 2:
Practice Address - City:BROWNWOOD
Practice Address - State:TX
Practice Address - Zip Code:76801-6822
Practice Address - Country:US
Practice Address - Phone:325-641-8800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8609111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX609763Medicare ID - Type UnspecifiedPROVIDER
TX8A6965Medicare ID - Type UnspecifiedINDIVIDUAL
TX00206VMedicare UPIN
TX00206VMedicare ID - Type UnspecifiedGROUP