Provider Demographics
NPI:1447335609
Name:KOTHLOW, BRADLEY ALLEN (DC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:ALLEN
Last Name:KOTHLOW
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 1:138 PLEASANT AVE
Mailing Address - Street 2:
Mailing Address - City:BALSAM LAKE
Mailing Address - State:WI
Mailing Address - Zip Code:54810-9019
Mailing Address - Country:US
Mailing Address - Phone:715-485-9352
Mailing Address - Fax:
Practice Address - Street 1:314 MAIN ST
Practice Address - Street 2:
Practice Address - City:BALSAM LAKE
Practice Address - State:WI
Practice Address - Zip Code:54810-7262
Practice Address - Country:US
Practice Address - Phone:715-485-3575
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2016012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38789500Medicaid
WI75778Medicare ID - Type Unspecified