Provider Demographics
NPI:1689610008
Name:BRADLEY EXTENDED CARE INC
Entity Type:Organization
Organization Name:BRADLEY EXTENDED CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:W
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:615-383-5391
Mailing Address - Street 1:402 53RD AVE N
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37209
Mailing Address - Country:US
Mailing Address - Phone:615-383-5391
Mailing Address - Fax:615-383-7365
Practice Address - Street 1:402 53RD AVE N
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37209
Practice Address - Country:US
Practice Address - Phone:615-383-5391
Practice Address - Fax:615-383-7365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-22
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
183500000X
TN40253336L0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes183500000XPharmacy Service ProvidersPharmacistGroup - Single Specialty
No3336L0003XSuppliersPharmacyLong Term Care PharmacyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4437477Medicaid
TN4437477Medicaid