=====================================================
General NPI Number Information
=====================================================
NPI Number | 1265600506
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FIRST COLONIAL CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/20/2008
-----------------------------------------------------
Last Update Date | 04/14/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1139 FIRST COLONIAL RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-496-4956
-----------------------------------------------------
Fax | 757-496-0197
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1139 FIRST COLONIAL RD
-----------------------------------------------------
City | VIRGINIA BEACH
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23454-2402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-496-4956
-----------------------------------------------------
Fax | 757-496-0197
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JASON A BRADECICH
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 757-496-4956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 0104555587
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------