Healthcare Provider Details

I. General information

NPI: 1861598211
Provider Name (Legal Business Name): MARC BRADLEY DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 ELM STREET
WEBER CITY VA
24290
US

IV. Provider business mailing address

111 ELM STREET
WEBER CITY VA
24290
US

V. Phone/Fax

Practice location:
  • Phone: 276-386-7778
  • Fax: 276-386-7857
Mailing address:
  • Phone: 276-386-7778
  • Fax: 276-386-7857

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number0104556003
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: