Provider Demographics
NPI:1669970158
Name:BRAKHAGE, BRYAN JON (DC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JON
Last Name:BRAKHAGE
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 1:2300 HUTTON RD STE 101
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:KS
Mailing Address - Zip Code:66109-4424
Mailing Address - Country:US
Mailing Address - Phone:913-721-0060
Mailing Address - Fax:
Practice Address - Street 1:2300 HUTTON RD STE 101
Practice Address - Street 2:
Practice Address - City:KANSAS CITY
Practice Address - State:KS
Practice Address - Zip Code:66109-4424
Practice Address - Country:US
Practice Address - Phone:913-721-0060
Practice Address - Fax:913-721-0060
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-30
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-05878111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty