Provider Demographics
NPI:1407828379
Name:BRADLEY S. DRAKE, PC
Entity Type:Organization
Organization Name:BRADLEY S. DRAKE, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRAD
Authorized Official - Middle Name:
Authorized Official - Last Name:DRAKE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:256-773-3997
Mailing Address - Street 1:697 HIGHWAY 31 NW
Mailing Address - Street 2:
Mailing Address - City:HARTSELLE
Mailing Address - State:AL
Mailing Address - Zip Code:35640-4408
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:697 HIGHWAY 31 NW
Practice Address - Street 2:SUITE 41
Practice Address - City:HARTSELLE
Practice Address - State:AL
Practice Address - Zip Code:35640-4408
Practice Address - Country:US
Practice Address - Phone:256-773-3997
Practice Address - Fax:256-773-3997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-02-06
Last Update Date:2023-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALS-A49-TA-629152W00000X
152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009937485Medicaid
AL=========OtherTAX ID NUMBER