Provider Demographics
NPI:1780782599
Name:SANDER, BRYAN J (DC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:J
Last Name:SANDER
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 1:715 WEST MAIN STREET
Mailing Address - Street 2:BAKKE CHIROPRACTIC CLINIC SC
Mailing Address - City:SUN PRAIRIE
Mailing Address - State:WI
Mailing Address - Zip Code:53590
Mailing Address - Country:US
Mailing Address - Phone:608-837-7600
Mailing Address - Fax:608-837-0633
Practice Address - Street 1:715 WEST MAIN STREET
Practice Address - Street 2:BAKKE CHIROPRACTIC CLINIC SC
Practice Address - City:SUN PRAIRIE
Practice Address - State:WI
Practice Address - Zip Code:53590
Practice Address - Country:US
Practice Address - Phone:608-837-7600
Practice Address - Fax:608-837-0633
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI3587012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38911100Medicaid
U74853Medicare UPIN