Provider Demographics
NPI:1609082478
Name:BRADFORD HOME INC.
Entity Type:Organization
Organization Name:BRADFORD HOME INC.
Other - Org Name:BRADFORD HOME, ICF DDN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ESTELITA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANGELISTA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:415-987-3401
Mailing Address - Street 1:59 BRADFORD DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-1129
Mailing Address - Country:US
Mailing Address - Phone:415-987-3401
Mailing Address - Fax:
Practice Address - Street 1:59 BRADFORD DR
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-1129
Practice Address - Country:US
Practice Address - Phone:415-987-3401
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55-G537OtherPROVIDER NUMBER