Provider Demographics
NPI:1215159637
Name:BRADLEE SPINE CENTER, PC
Entity type:Organization
Organization Name:BRADLEE SPINE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:KEITH
Authorized Official - Last Name:SOLOMON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:703-379-4055
Mailing Address - Street 1:3541 W. BRADDOCK ROAD SUITE 203
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:VA
Mailing Address - Zip Code:22032-1902
Mailing Address - Country:US
Mailing Address - Phone:703-379-4055
Mailing Address - Fax:703-379-1099
Practice Address - Street 1:3541 W. BRADDOCK ROAD SUITE 203
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:VA
Practice Address - Zip Code:22032-1902
Practice Address - Country:US
Practice Address - Phone:703-379-4055
Practice Address - Fax:703-379-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001984111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCU80482Medicare UPIN
DCG02236Medicare ID - Type Unspecified