Provider Demographics
NPI:1548242183
Name:RETHWILL, BRADLEY K (DC)
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:K
Last Name:RETHWILL
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 1:1400 EXECUTIVE PKWY STE 220
Mailing Address - Street 2:
Mailing Address - City:EUGENE
Mailing Address - State:OR
Mailing Address - Zip Code:97401-7109
Mailing Address - Country:US
Mailing Address - Phone:541-345-1669
Mailing Address - Fax:541-359-2238
Practice Address - Street 1:1400 EXECUTIVE PKWY STE 220
Practice Address - Street 2:
Practice Address - City:EUGENE
Practice Address - State:OR
Practice Address - Zip Code:97401-7109
Practice Address - Country:US
Practice Address - Phone:541-345-1669
Practice Address - Fax:541-359-2238
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-18
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1834111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000QGCNSMedicare PIN
ORT68047Medicare UPIN