Provider Demographics
NPI:1447203013
Name:BELLEVUE TOTAL HEALTH, SC
Entity Type:Organization
Organization Name:BELLEVUE TOTAL HEALTH, SC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:KENNY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:920-468-8288
Mailing Address - Street 1:2763 MANITOWOC RD
Mailing Address - Street 2:STE B
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54311-6633
Mailing Address - Country:US
Mailing Address - Phone:920-468-8288
Mailing Address - Fax:920-468-9887
Practice Address - Street 1:2763 MANITOWOC RD
Practice Address - Street 2:STE B
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6633
Practice Address - Country:US
Practice Address - Phone:920-468-8288
Practice Address - Fax:920-468-9887
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2502-012111N00000X
WI4214-012111N00000X
WI25884-020207R00000X
WI1221-033363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI21250700Medicaid
WI39002800Medicaid