Healthcare Provider Details

I. General information

NPI: 1801888342
Provider Name (Legal Business Name): BRADLEY ROBERT THOMSEN D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 05/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2534 17TH AVE S SUITE 2D
GRAND FORKS ND
58201-5215
US

IV. Provider business mailing address

PO BOX 12875
GRAND FORKS ND
58208-2875
US

V. Phone/Fax

Practice location:
  • Phone: 701-746-8636
  • Fax: 701-746-8827
Mailing address:
  • Phone: 701-746-8636
  • Fax: 701-746-8827

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number649
License Number StateND

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: