Provider Demographics
NPI:1558706101
Name:BRADY, JOHN RICHARD IV (LVN)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:BRADY
Suffix:IV
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3853 ROSECRANS ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-692-8232
Mailing Address - Fax:619-542-4060
Practice Address - Street 1:3047 LLOYD ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-6033
Practice Address - Country:US
Practice Address - Phone:619-723-2492
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2013-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN231435164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse