Provider Demographics
NPI:1588785265
Name:MACK, BRADLEY DEAN (LATC)
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:DEAN
Last Name:MACK
Suffix:
Gender:M
Credentials:LATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3749 DENMARK TRL W
Mailing Address - Street 2:
Mailing Address - City:EAGAN
Mailing Address - State:MN
Mailing Address - Zip Code:55123-1010
Mailing Address - Country:US
Mailing Address - Phone:651-688-0960
Mailing Address - Fax:
Practice Address - Street 1:4185 BRADDOCK TRL
Practice Address - Street 2:
Practice Address - City:EAGAN
Practice Address - State:MN
Practice Address - Zip Code:55123-1575
Practice Address - Country:US
Practice Address - Phone:651-683-6945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN15682255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer