Healthcare Provider Details

I. General information

NPI: 1558350678
Provider Name (Legal Business Name): BRADLEY W NEUJAHR OD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/20/2005
Last Update Date: 11/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 2ND ST NE
BAGLEY MN
56621
US

IV. Provider business mailing address

PO BOX J 14 2ND ST NE
BAGLEY MN
56621-1008
US

V. Phone/Fax

Practice location:
  • Phone: 218-694-2442
  • Fax: 218-694-2446
Mailing address:
  • Phone: 218-694-2442
  • Fax: 218-694-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1892
License Number StateMN

VIII. Authorized Official

Name: DR. BRADLEY WAYNE NEUJAHR
Title or Position: CEO OWNER
Credential: OD
Phone: 218-694-2442