Provider Demographics
NPI:1003905241
Name:BOULTON, BRADLEY JAMES (DC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JAMES
Last Name:BOULTON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-0308
Mailing Address - Country:US
Mailing Address - Phone:989-539-5201
Mailing Address - Fax:
Practice Address - Street 1:190 S SECOND ST
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625
Practice Address - Country:US
Practice Address - Phone:989-539-5201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301005243111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor