Provider Demographics
NPI:1366449696
Name:BOSMA, BRADLEY RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:RICHARD
Last Name:BOSMA
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 1:202 PLUM RD. STE A
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSTOWN
Mailing Address - State:WI
Mailing Address - Zip Code:54180-1253
Mailing Address - Country:US
Mailing Address - Phone:920-532-6450
Mailing Address - Fax:
Practice Address - Street 1:202 PLUM RD. STE A
Practice Address - Street 2:STE 4
Practice Address - City:WRIGHTSTOWN
Practice Address - State:WI
Practice Address - Zip Code:54180-1253
Practice Address - Country:US
Practice Address - Phone:920-532-6450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3807-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI389-36600Medicaid
WI0000-07065Medicare ID - Type Unspecified