Healthcare Provider Details

I. General information

NPI: 1922106590
Provider Name (Legal Business Name): KEVIN G. BRADLEY P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
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
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: DR. KEVIN GARNER BRADLEY
Title or Position: PRESIDENT/OWNER
Credential: D.C.
Phone: 918-689-2424