Provider Demographics
NPI:1376278721
Name:BOOTH, BRADLEY
Entity Type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:BOOTH
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:V538 COUNTY ROAD 4A
Mailing Address - Street 2:
Mailing Address - City:LIBERTY CENTER
Mailing Address - State:OH
Mailing Address - Zip Code:43532-8512
Mailing Address - Country:US
Mailing Address - Phone:419-966-6384
Mailing Address - Fax:
Practice Address - Street 1:V538 COUNTY ROAD 4A
Practice Address - Street 2:
Practice Address - City:LIBERTY CENTER
Practice Address - State:OH
Practice Address - Zip Code:43532-8512
Practice Address - Country:US
Practice Address - Phone:419-966-6384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-20
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider