Healthcare Provider Details

I. General information

NPI: 1447335609
Provider Name (Legal Business Name): BRADLEY ALLEN KOTHLOW D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

314 MAIN ST
BALSAM LAKE WI
54810-7262
US

IV. Provider business mailing address

138 PLEASANT AVE
BALSAM LAKE WI
54810-9019
US

V. Phone/Fax

Practice location:
  • Phone: 715-485-3575
  • Fax:
Mailing address:
  • Phone: 715-485-9352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2016012
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: