Provider Demographics
NPI:1881737666
Name:DYCK, BRADLEY (DC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:DYCK
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:PO BOX 4081
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93447-4081
Mailing Address - Country:US
Mailing Address - Phone:805-238-6004
Mailing Address - Fax:805-238-6085
Practice Address - Street 1:1020 17TH ST
Practice Address - Street 2:
Practice Address - City:PASO ROBLES
Practice Address - State:CA
Practice Address - Zip Code:93446-1700
Practice Address - Country:US
Practice Address - Phone:805-238-6004
Practice Address - Fax:805-238-6085
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU86571Medicare UPIN