Provider Demographics
NPI:1194414029
Name:WALLING, BRADLEY PHILIP (DC)
Entity type:Individual
Prefix:DR
First Name:BRADLEY
Middle Name:PHILIP
Last Name:WALLING
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 1:5570 WILSON AVE SW STE MN
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49418-8867
Mailing Address - Country:US
Mailing Address - Phone:616-259-8935
Mailing Address - Fax:
Practice Address - Street 1:5570 WILSON AVE SW STE MN
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49418-8867
Practice Address - Country:US
Practice Address - Phone:616-259-8935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-05
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301401420111N00000X
MI2031401420111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty