Provider Demographics
NPI:1780763862
Name:BRADY, JEFFREY (DC)
Entity type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BRADY
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 1:454 FOREST SQ
Mailing Address - Street 2:
Mailing Address - City:LONGVIEW
Mailing Address - State:TX
Mailing Address - Zip Code:75605-4401
Mailing Address - Country:US
Mailing Address - Phone:903-757-6162
Mailing Address - Fax:903-757-7722
Practice Address - Street 1:454 FOREST SQ
Practice Address - Street 2:
Practice Address - City:LONGVIEW
Practice Address - State:TX
Practice Address - Zip Code:75605-4401
Practice Address - Country:US
Practice Address - Phone:903-757-6162
Practice Address - Fax:903-757-7722
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX8337111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8768B6Medicare ID - Type UnspecifiedINDIVIDUAL MEDICARE #
TXU78570Medicare UPIN
TX00699TMedicare ID - Type UnspecifiedGROUP MEDICARE #