Provider Demographics
NPI:1528211562
Name:BRADFORD, BRYAN RICHARD (CN)
Entity Type:Individual
Prefix:MR
First Name:BRYAN
Middle Name:RICHARD
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5100 STATE HIGHWAY 121
Mailing Address - Street 2:SUITE A
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-5934
Mailing Address - Country:US
Mailing Address - Phone:817-399-9100
Mailing Address - Fax:817-399-9909
Practice Address - Street 1:5100 STATE HIGHWAY 121
Practice Address - Street 2:SUITE A
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-5934
Practice Address - Country:US
Practice Address - Phone:817-399-9100
Practice Address - Fax:817-399-9909
Is Sole Proprietor?:Yes
Enumeration Date:2008-11-03
Last Update Date:2008-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO001146133NN1002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education