Provider Demographics
NPI:1457357840
Name:SHULL, BRADFORD LEWIS (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADFORD
Middle Name:LEWIS
Last Name:SHULL
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 1:202 S INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:NEVADA
Mailing Address - State:MO
Mailing Address - Zip Code:64772-3978
Mailing Address - Country:US
Mailing Address - Phone:417-667-4322
Mailing Address - Fax:417-667-8997
Practice Address - Street 1:202 S INDIANA ST
Practice Address - Street 2:
Practice Address - City:NEVADA
Practice Address - State:MO
Practice Address - Zip Code:64772-3978
Practice Address - Country:US
Practice Address - Phone:417-667-4322
Practice Address - Fax:417-667-8997
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-22
Last Update Date:2010-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO005736111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO0001389OtherMEDICARE PTAN
MO16346025OtherBCBS
MO1457357840OtherNPI
MO0001389OtherMEDICARE PTAN