Provider Demographics
NPI:1871605808
Name:BRADLEY, SHAWN (DC)
Entity type:Individual
Prefix:MR
First Name:SHAWN
Middle Name:
Last Name:BRADLEY
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 1:1761 JEFFCO BLVD
Mailing Address - Street 2:
Mailing Address - City:ARNOLD
Mailing Address - State:MO
Mailing Address - Zip Code:63010-2713
Mailing Address - Country:US
Mailing Address - Phone:636-296-1222
Mailing Address - Fax:636-296-1226
Practice Address - Street 1:1761 JEFFCO BLVD
Practice Address - Street 2:
Practice Address - City:ARNOLD
Practice Address - State:MO
Practice Address - Zip Code:63010-2713
Practice Address - Country:US
Practice Address - Phone:636-296-1222
Practice Address - Fax:636-296-1226
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2008-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004018211111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOP00453018OtherMEDICARE RAILROAD PIN
MO192583OtherBCBS PROVIDER NUMBER
MO2247716OtherFIRST HEALTH PROVIDER #
MO686170OtherHEALTHLINK PROVIDER #
MO228713OtherGHP PIN
MO686170OtherHEALTHLINK PROVIDER #
MOV03361Medicare UPIN