Basic Information
| Provider Information | |||||||||
| NPI: | 1740544188 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | BLAIRE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 700688 | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782700688 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2104777654 | ||||||||
| FaxNumber: | 2104680682 | ||||||||
| Practice Location | |||||||||
| Address1: | 900 S 336TH ST | ||||||||
| Address2: | |||||||||
| City: | FEDERAL WAY | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980036311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004046050 | ||||||||
| FaxNumber: | 8663133397 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2012 | ||||||||
| LastUpdateDate: | 09/11/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 111N00000X | 38MC00690000 | NJ | N | Chiropractic Providers | Chiropractor | 111N00000X | 12034 | TX | N | Chiropractic Providers | Chiropractor | 111N00000X | CH60710394 | WA | Y | Chiropractic Providers | Chiropractor |
ID Information
| ID | Type | State | Issuer | Description | CH60710394 | 01 | WA | WASHINGTON STATE DEPARTMENT OF HEALTH | OTHER |