Provider Demographics
NPI:1477881092
Name:BRADLEY FOOTCARE LLC
Entity Type:Organization
Organization Name:BRADLEY FOOTCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:JESSE
Authorized Official - Middle Name:H
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:JR
Authorized Official - Credentials:DPM
Authorized Official - Phone:870-733-0888
Mailing Address - Street 1:PO BOX 1752
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72303-1752
Mailing Address - Country:US
Mailing Address - Phone:870-733-0888
Mailing Address - Fax:870-733-0889
Practice Address - Street 1:116 W TYLER AVE STE B
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-733-0888
Practice Address - Fax:870-733-0889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-11-19
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR242213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR180372748Medicaid
AR180310717Medicaid
AR199945716Medicaid