Provider Demographics
NPI:1588623482
Name:KENNY, BRADLEY JOHN (DC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:JOHN
Last Name:KENNY
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 1:1702 SCHEURING RD STE C
Mailing Address - Street 2:
Mailing Address - City:DE PERE
Mailing Address - State:WI
Mailing Address - Zip Code:54115-9567
Mailing Address - Country:US
Mailing Address - Phone:920-227-1331
Mailing Address - Fax:920-632-7870
Practice Address - Street 1:1702 SCHEURING RD STE C
Practice Address - Street 2:
Practice Address - City:DE PERE
Practice Address - State:WI
Practice Address - Zip Code:54115-9567
Practice Address - Country:US
Practice Address - Phone:920-227-1331
Practice Address - Fax:920-632-7870
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2023-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2502-012111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38930200Medicaid
WIT95290Medicare UPIN
WI38930200Medicaid