Provider Demographics
NPI:1831271048
Name:DR BRADLEY A CHICOINE PC
Entity type:Organization
Organization Name:DR BRADLEY A CHICOINE PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHICOINE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:712-252-0633
Mailing Address - Street 1:1501 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51105-1240
Mailing Address - Country:US
Mailing Address - Phone:712-252-0633
Mailing Address - Fax:712-252-3904
Practice Address - Street 1:1501 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51105-1240
Practice Address - Country:US
Practice Address - Phone:712-252-0633
Practice Address - Fax:712-252-3904
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-19
Last Update Date:2015-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA05627111N00000X
IA04520111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA29618OtherWELLMARK BCBS
IA0157800Medicaid
IA5152033Medicaid
IA29712OtherWELLMARK BCBS
IA5152033Medicaid
IA0157800Medicaid
IA15780Medicare ID - Type Unspecified