Provider Demographics
NPI:1447251533
Name:BRADHAM, DAVID L (DC)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:L
Last Name:BRADHAM
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 506
Mailing Address - Street 2:
Mailing Address - City:ERWIN
Mailing Address - State:NC
Mailing Address - Zip Code:28339-0506
Mailing Address - Country:US
Mailing Address - Phone:910-892-1119
Mailing Address - Fax:910-892-1614
Practice Address - Street 1:407-K EAST JACKSON BLVD
Practice Address - Street 2:
Practice Address - City:ERWIN
Practice Address - State:NC
Practice Address - Zip Code:28339-9628
Practice Address - Country:US
Practice Address - Phone:910-892-1119
Practice Address - Fax:910-892-1614
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2481111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC0830TOtherBLUE CROSS BLUE SHIELD
NC8902671Medicaid
NC2452359Medicare ID - Type Unspecified
NC8902671Medicaid