Provider Demographics
NPI:1992709927
Name:POWELL, BRADLEY B (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:B
Last Name:POWELL
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 1:24582 DEL PRADO
Mailing Address - Street 2:STE H
Mailing Address - City:DANA POINT
Mailing Address - State:CA
Mailing Address - Zip Code:92629-3821
Mailing Address - Country:US
Mailing Address - Phone:949-487-2722
Mailing Address - Fax:949-487-2723
Practice Address - Street 1:24582 DEL PRADO
Practice Address - Street 2:STE H
Practice Address - City:DANA POINT
Practice Address - State:CA
Practice Address - Zip Code:92629-3821
Practice Address - Country:US
Practice Address - Phone:949-487-2722
Practice Address - Fax:949-487-2723
Is Sole Proprietor?:No
Enumeration Date:2005-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC27515111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0275150OtherBLUE SHIELD
CADC27515Medicare ID - Type Unspecified