Healthcare Provider Details

I. General information

NPI: 1881925873
Provider Name (Legal Business Name): AMANDA JO SMITH-BRADWAY D.C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/15/2010
Last Update Date: 01/07/2020
Certification Date: 01/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 W 6TH ST
JASPER IN
47546-2629
US

IV. Provider business mailing address

810 CRESTWOOD DR
JASPER IN
47546-8458
US

V. Phone/Fax

Practice location:
  • Phone: 812-345-1930
  • Fax:
Mailing address:
  • Phone: 812-345-1930
  • Fax: 812-482-6350

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number08002498A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number08002498A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: