Provider Demographics
NPI:1932899150
Name:BREDESON, BLAKE (DC)
Entity Type:Individual
Prefix:
First Name:BLAKE
Middle Name:
Last Name:BREDESON
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 1:28425 133RD ST NW
Mailing Address - Street 2:
Mailing Address - City:ZIMMERMAN
Mailing Address - State:MN
Mailing Address - Zip Code:55398-9229
Mailing Address - Country:US
Mailing Address - Phone:763-221-2654
Mailing Address - Fax:
Practice Address - Street 1:19112 FREEPORT ST NW STE E117
Practice Address - Street 2:
Practice Address - City:ELK RIVER
Practice Address - State:MN
Practice Address - Zip Code:55330-1267
Practice Address - Country:US
Practice Address - Phone:763-221-2654
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-10
Last Update Date:2023-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6041111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor