Provider Demographics
NPI:1720149545
Name:PRUETT, BRADLEY (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:PRUETT
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 1:4844 N FIRST STREET
Mailing Address - Street 2:#102
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93726
Mailing Address - Country:US
Mailing Address - Phone:559-225-1796
Mailing Address - Fax:559-225-1798
Practice Address - Street 1:4844 N FIRST STREET
Practice Address - Street 2:#102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93726
Practice Address - Country:US
Practice Address - Phone:559-225-1796
Practice Address - Fax:559-225-1798
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC203550111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC203550Medicare ID - Type Unspecified