Provider Demographics
NPI:1376055970
Name:BURGESS, BRADLEY (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:
Last Name:BURGESS
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 1:8645 SAN MARCO BLVD
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48313-4861
Mailing Address - Country:US
Mailing Address - Phone:586-556-1060
Mailing Address - Fax:
Practice Address - Street 1:39880 VAN DYKE AVE STE 201
Practice Address - Street 2:
Practice Address - City:STERLING HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48313-4670
Practice Address - Country:US
Practice Address - Phone:586-745-1021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-04
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301010613111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty