Provider Demographics
NPI:1043564610
Name:BREYAN RADECK DC, LLC
Entity Type:Organization
Organization Name:BREYAN RADECK DC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:BREYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADECK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:262-349-9370
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-05
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4494012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043453426Medicaid