Provider Demographics
NPI:1750645669
Name:WIEGAND, BRADLEY JAMES (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JAMES
Last Name:WIEGAND
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 1:126 E MILL ST
Mailing Address - Street 2:
Mailing Address - City:PLYMOUTH
Mailing Address - State:WI
Mailing Address - Zip Code:53073-1704
Mailing Address - Country:US
Mailing Address - Phone:920-892-8920
Mailing Address - Fax:920-892-8920
Practice Address - Street 1:4027 S BUSINESS DR
Practice Address - Street 2:
Practice Address - City:SHEBOYGAN
Practice Address - State:WI
Practice Address - Zip Code:53081-1261
Practice Address - Country:US
Practice Address - Phone:920-459-9090
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2015-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4891111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor