Provider Demographics
NPI:1366535668
Name:BRADLEY, DAVID BRIAN (DC CCRD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:BRIAN
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:DC CCRD
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 1794
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76053-1794
Mailing Address - Country:US
Mailing Address - Phone:817-282-7600
Mailing Address - Fax:817-282-7604
Practice Address - Street 1:1228 PRECINCT LINE RD
Practice Address - Street 2:#B
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76053-4290
Practice Address - Country:US
Practice Address - Phone:817-282-7600
Practice Address - Fax:817-282-7604
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2009-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX4202111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8F22315Medicare PIN
TX601578Medicare ID - Type Unspecified