Healthcare Provider Details

I. General information

NPI: 1144330945
Provider Name (Legal Business Name): DR. BRADLEY RAY DRAKE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1315 MAIN STREET
MT VERNON IL
62864-3720
US

IV. Provider business mailing address

1315 MAIN STREET
MT VERNON IL
62864-3720
US

V. Phone/Fax

Practice location:
  • Phone: 618-242-4554
  • Fax: 618-242-4653
Mailing address:
  • Phone: 618-242-4554
  • Fax: 618-242-4653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: