Provider Demographics
NPI:1447376082
Name:WATERS, BRADLEY KENT (DC, DICCP)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:KENT
Last Name:WATERS
Suffix:
Gender:M
Credentials:DC, DICCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:410 S ORCHARD ST STE 120
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83705-1210
Mailing Address - Country:US
Mailing Address - Phone:208-336-7963
Mailing Address - Fax:
Practice Address - Street 1:410 S ORCHARD ST STE 120
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83705-1210
Practice Address - Country:US
Practice Address - Phone:208-336-7963
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-22
Last Update Date:2024-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDCHIA-2357111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAU20435Medicare UPIN