Provider Demographics
NPI:1043894165
Name:POLEN, BRADLEY JACK (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:JACK
Last Name:POLEN
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 1:203 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-2345
Mailing Address - Country:US
Mailing Address - Phone:618-254-9355
Mailing Address - Fax:618-254-9351
Practice Address - Street 1:203 S 6TH ST
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-2345
Practice Address - Country:US
Practice Address - Phone:618-254-9355
Practice Address - Fax:618-254-9351
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-06
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2021016090111N00000X
IL038.013756111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty