Provider Demographics
NPI:1699886390
Name:ENNIS, BRADLEY D (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:D
Last Name:ENNIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1526 N ATHERTON ST STE 200
Mailing Address - Street 2:
Mailing Address - City:STATE COLLEGE
Mailing Address - State:PA
Mailing Address - Zip Code:16803-3041
Mailing Address - Country:US
Mailing Address - Phone:814-237-5220
Mailing Address - Fax:412-291-3381
Practice Address - Street 1:1526 N ATHERTON ST STE 200
Practice Address - Street 2:
Practice Address - City:STATE COLLEGE
Practice Address - State:PA
Practice Address - Zip Code:16803
Practice Address - Country:US
Practice Address - Phone:814-237-5220
Practice Address - Fax:412-291-3381
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2019-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PADC007593L111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
347952OtherHIGHMARK BC/BS
03081900OtherCAPITAL BC/BS