Provider Demographics
NPI:1750662417
Name:BRADLEY, DARYL (IDMT)
Entity Type:Individual
Prefix:MR
First Name:DARYL
Middle Name:
Last Name:BRADLEY
Suffix:
Gender:M
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:146 TULANE DR
Mailing Address - Street 2:
Mailing Address - City:RAEFORD
Mailing Address - State:NC
Mailing Address - Zip Code:28376-8006
Mailing Address - Country:US
Mailing Address - Phone:910-224-3304
Mailing Address - Fax:
Practice Address - Street 1:146 TULANE DR
Practice Address - Street 2:
Practice Address - City:RAEFORD
Practice Address - State:NC
Practice Address - Zip Code:28376
Practice Address - Country:US
Practice Address - Phone:910-394-6040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-07
Last Update Date:2011-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians