=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417399981
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TYBRADSHAW CHIROPRACTIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/24/2013
-----------------------------------------------------
Last Update Date | 07/24/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4179 E FAIRBANKS ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-6148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 801-859-9485
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4179 E FAIRBANKS ST
-----------------------------------------------------
City | GILBERT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 85295-6148
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIROPRACTOR
-----------------------------------------------------
Name | TYLER BRADSHAW
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 801-859-9485
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 8338
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------