Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 038013262 | IL |
N | 111NS0005X | Chiropractic Sports Physician | 093348 | IA |
N | 111NS0005X | Chiropractic Sports Physician | 5079-12 | WI |
NPI | 1144684564 |
---|---|
Provider Name | Dr. Bradley Brunner |
First Address | Lena, IL 61048-8822 |
Second Address | Lena, IL 61048-8822 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 12/04/2016 |
Last Update Date | 03/12/2018 |