Provider Demographics
NPI:1750445318
Name:BRADLEY I. HALL, O.D., P.C.
Entity Type:Organization
Organization Name:BRADLEY I. HALL, O.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:INGALLS
Authorized Official - Last Name:HALL
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:707-570-2418
Mailing Address - Street 1:1900 SANTA ROSA AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-7621
Mailing Address - Country:US
Mailing Address - Phone:707-570-2418
Mailing Address - Fax:707-578-2076
Practice Address - Street 1:1900 SANTA ROSA AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-7621
Practice Address - Country:US
Practice Address - Phone:707-570-2418
Practice Address - Fax:707-578-2076
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-20
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACOR 1054152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty