Provider Demographics
NPI:1326361098
Name:BRADLEY SMITH INNOVATIVE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:BRADLEY SMITH INNOVATIVE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:J
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:707-533-3170
Mailing Address - Street 1:P.O. BOX 551
Mailing Address - Street 2:
Mailing Address - City:KELSEYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95451-0551
Mailing Address - Country:US
Mailing Address - Phone:707-533-3170
Mailing Address - Fax:
Practice Address - Street 1:5289 STATE ST.
Practice Address - Street 2:
Practice Address - City:KELSEYVILLE
Practice Address - State:CA
Practice Address - Zip Code:95451-9449
Practice Address - Country:US
Practice Address - Phone:707-533-3170
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-09
Last Update Date:2010-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT22821225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty