Healthcare Provider Details

I. General information

NPI: 1609971241
Provider Name (Legal Business Name): KEVIN G. BRADLEY CH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: KEVIN GARNER BRADLEY D.C.

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 03/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 ALEXANDER DR STE 107
EUFAULA OK
74432-4013
US

IV. Provider business mailing address

PO BOX 930 640 ALEXANDER SUITE 107
EUFAULA OK
74432-0930
US

V. Phone/Fax

Practice location:
  • Phone: 918-689-2424
  • Fax: 918-618-4778
Mailing address:
  • Phone: 918-689-2424
  • Fax: 918-618-4778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3321
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: