Provider Demographics
NPI:1790204832
Name:RADERMACHER, GRANT KEITH (DC)
Entity Type:Individual
Prefix:
First Name:GRANT
Middle Name:KEITH
Last Name:RADERMACHER
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 1:16620 W BLUEMOUND RD
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-5966
Mailing Address - Country:US
Mailing Address - Phone:262-345-4166
Mailing Address - Fax:
Practice Address - Street 1:16620 W BLUEMOUND RD
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53005-5966
Practice Address - Country:US
Practice Address - Phone:262-345-4166
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-10
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4707111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor