Provider Demographics
NPI:1740359652
Name:HOUSE, G BRADFORD (DC)
Entity type:Individual
Prefix:
First Name:G
Middle Name:BRADFORD
Last Name:HOUSE
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 1:208 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-3225
Mailing Address - Country:US
Mailing Address - Phone:731-885-1144
Mailing Address - Fax:731-885-1157
Practice Address - Street 1:208 W MAIN ST
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:TN
Practice Address - Zip Code:38261-3225
Practice Address - Country:US
Practice Address - Phone:731-885-1144
Practice Address - Fax:731-885-1157
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2007-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC423111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0043951OtherBLUE CROSS TN PROVIDER ID
TN3673478Medicare ID - Type UnspecifiedMEDICARE IDENIFICATION
TN0043951OtherBLUE CROSS TN PROVIDER ID