Provider Demographics
NPI:1669531885
Name:BRIA, JEREMY L (DC)
Entity type:Individual
Prefix:MR
First Name:JEREMY
Middle Name:L
Last Name:BRIA
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 1:450 MILL ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:FONTANA
Mailing Address - State:WI
Mailing Address - Zip Code:53125-1242
Mailing Address - Country:US
Mailing Address - Phone:262-275-5005
Mailing Address - Fax:262-275-5004
Practice Address - Street 1:450 MILL ST
Practice Address - Street 2:SUITE 102
Practice Address - City:FONTANA
Practice Address - State:WI
Practice Address - Zip Code:53125-1242
Practice Address - Country:US
Practice Address - Phone:262-275-5005
Practice Address - Fax:262-275-5004
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4188-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38966200Medicaid