MEDICARE: MR. BRADLEY ALLEN KOTHLOW D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	2016012	WI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1447335609
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRADLEY ALLEN KOTHLOW D.C.

Provider Business Mailing Address
First Line	:	138 PLEASANT AVE
Second Line	:
City	:	BALSAM LAKE
State	:	WI
Zip	:	54810-9019
Country	:	US
Telephone Number	:	715-485-9352
Fax Number	:

Provider Business Practice Location Address
First Line	:	314 MAIN ST
Second Line	:
City	:	BALSAM LAKE
State	:	WI
Zip	:	54810-7262
Country	:	US
Telephone Number	:	715-485-3575
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/26/2006
Last Update Date	:	07/08/2007

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