Provider Demographics
NPI:1942341375
Name:WEISS, BRADLEY G (DC)
Entity Type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:G
Last Name:WEISS
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 1:4343 10TH AVE N
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33461
Mailing Address - Country:US
Mailing Address - Phone:561-964-6077
Mailing Address - Fax:561-964-1253
Practice Address - Street 1:11924 W FOREST HILL BLVD
Practice Address - Street 2:SUITE 13
Practice Address - City:WELLINGTON
Practice Address - State:FL
Practice Address - Zip Code:33414
Practice Address - Country:US
Practice Address - Phone:561-964-6077
Practice Address - Fax:561-753-6095
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH0005180111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T85495Medicare UPIN
FL70730Medicare ID - Type Unspecified