Provider Demographics
NPI:1538373170
Name:BRADLEY, GLENN ROBERT (DC)
Entity type:Individual
Prefix:
First Name:GLENN
Middle Name:ROBERT
Last Name:BRADLEY
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 1:56 LEIGH ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NJ
Mailing Address - Zip Code:08809-1349
Mailing Address - Country:US
Mailing Address - Phone:908-238-9913
Mailing Address - Fax:973-484-2920
Practice Address - Street 1:909 ELIZABETH AVE
Practice Address - Street 2:
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07201-2710
Practice Address - Country:US
Practice Address - Phone:908-629-0779
Practice Address - Fax:908-629-0804
Is Sole Proprietor?:No
Enumeration Date:2007-05-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ38MC00547600111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor