Basic Information
| Provider Information | |||||||||
| NPI: | 1265745244 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BRAD JAMISON CHIROPRACTIC, P.L.L.C. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 671 S WOODRUFF AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085522584 | ||||||||
| FaxNumber: | 2085293992 | ||||||||
| Practice Location | |||||||||
| Address1: | 671 S WOODRUFF AVE | ||||||||
| Address2: | |||||||||
| City: | IDAHO FALLS | ||||||||
| State: | ID | ||||||||
| PostalCode: | 834015596 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2085522584 | ||||||||
| FaxNumber: | 2085293992 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2010 | ||||||||
| LastUpdateDate: | 08/09/2010 | ||||||||
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| AuthorizedOfficialLastName: | JAMISON | ||||||||
| AuthorizedOfficialFirstName: | NOLAN | ||||||||
| AuthorizedOfficialMiddleName: | BRADLEY | ||||||||
| AuthorizedOfficialTitleorPosition: | DOCTOR / OWNER | ||||||||
| AuthorizedOfficialTelephone: | 2085522584 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | D.C. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | CHIA467 | ID | Y | 193400000X SINGLE SPECIALTY GROUP | Chiropractic Providers | Chiropractor |
No ID Information.