Provider Demographics
NPI:1174646251
Name:CONRAD, BRADLEY DEAN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:DEAN
Last Name:CONRAD
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 1:3674 BLUEBIRD AVE SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-3167
Mailing Address - Country:US
Mailing Address - Phone:616-249-3192
Mailing Address - Fax:
Practice Address - Street 1:3651 BYRON CENTER AVE SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-3665
Practice Address - Country:US
Practice Address - Phone:616-530-0151
Practice Address - Fax:616-530-0205
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-06
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006548111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1972685Medicaid
MI950D150450OtherBCBS
MI1972685Medicaid