Provider Demographics
NPI:1871664219
Name:VIRGIN, BRADLEY KEITH (DC,CCSP)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:KEITH
Last Name:VIRGIN
Suffix:
Gender:M
Credentials:DC,CCSP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 E UNION AVE
Mailing Address - Street 2:
Mailing Address - City:LITCHFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62056-1519
Mailing Address - Country:US
Mailing Address - Phone:217-324-2377
Mailing Address - Fax:217-324-2377
Practice Address - Street 1:311 E UNION AVE
Practice Address - Street 2:
Practice Address - City:LITCHFIELD
Practice Address - State:IL
Practice Address - Zip Code:62056-1519
Practice Address - Country:US
Practice Address - Phone:217-324-2377
Practice Address - Fax:217-324-2377
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL679810Medicare ID - Type Unspecified
IL679810Medicare PIN