Provider Demographics
NPI:1699118042
Name:SCHLEENBAKER, BRADLEY EUGENE
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:EUGENE
Last Name:SCHLEENBAKER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 W 7200 S
Mailing Address - Street 2:SUITE A
Mailing Address - City:MIDVALE
Mailing Address - State:UT
Mailing Address - Zip Code:84047-1043
Mailing Address - Country:US
Mailing Address - Phone:801-858-3461
Mailing Address - Fax:801-955-2389
Practice Address - Street 1:1388 S NAVAJO ST
Practice Address - Street 2:SUITE C
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84104-3493
Practice Address - Country:US
Practice Address - Phone:801-955-2360
Practice Address - Fax:877-497-4661
Is Sole Proprietor?:No
Enumeration Date:2013-04-15
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9195407-1205207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program