Provider Demographics
NPI:1790741569
Name:BRADSHAW HOME MEDICAL EQUIPMENT LLC.
Entity Type:Organization
Organization Name:BRADSHAW HOME MEDICAL EQUIPMENT LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-775-8282
Mailing Address - Street 1:9350 E VALLEY RD
Mailing Address - Street 2:STE C.
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2328
Mailing Address - Country:US
Mailing Address - Phone:928-775-8282
Mailing Address - Fax:928-775-8869
Practice Address - Street 1:9350 E VALLEY RD
Practice Address - Street 2:STE C.
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2328
Practice Address - Country:US
Practice Address - Phone:928-775-8282
Practice Address - Fax:928-775-8869
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ20102224332BX2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332BX2000XSuppliersDurable Medical Equipment & Medical SuppliesOxygen Equipment & Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ022261Medicaid
AZ5609690001Medicare NSC