Provider Demographics
NPI:1043453426
Name:RADECK, BREYAN MICHELLE (DC)
Entity Type:Individual
Prefix:DR
First Name:BREYAN
Middle Name:MICHELLE
Last Name:RADECK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2717 N GRANDVIEW BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188-1672
Mailing Address - Country:US
Mailing Address - Phone:262-349-9370
Mailing Address - Fax:262-349-9729
Practice Address - Street 1:2717 N GRANDVIEW BLVD STE 101
Practice Address - Street 2:
Practice Address - City:WAUKESHA
Practice Address - State:WI
Practice Address - Zip Code:53188-1672
Practice Address - Country:US
Practice Address - Phone:262-349-9370
Practice Address - Fax:262-349-9729
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-14
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4494012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor