Healthcare Provider Details

I. General information

NPI: 1184959249
Provider Name (Legal Business Name): BRADLEY VERNON NORTHRUP D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/07/2009
Last Update Date: 04/26/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1053 GRAND AVE #114
SAINT PAUL MN
55105-3022
US

IV. Provider business mailing address

1053 GRAND AVE #114
SAINT PAUL MN
55105-3022
US

V. Phone/Fax

Practice location:
  • Phone: 651-292-9247
  • Fax:
Mailing address:
  • Phone: 651-292-9247
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5324
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: