Provider Demographics
NPI:1689025405
Name:GROLEAU, BRADLEY
Entity type:Individual
Prefix:MR
First Name:BRADLEY
Middle Name:
Last Name:GROLEAU
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 1:2995 CARRIE ST
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1387
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2995 CARRIE ST
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1387
Practice Address - Country:US
Practice Address - Phone:815-830-7934
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-22
Last Update Date:2016-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program