Provider Demographics
NPI:1841423456
Name:BRADLEY, GREGORY MAURICE JR (LMBT)
Entity Type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:MAURICE
Last Name:BRADLEY
Suffix:JR
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:269 HORIZON CIR
Mailing Address - Street 2:
Mailing Address - City:ROCK HILL
Mailing Address - State:SC
Mailing Address - Zip Code:29732-7628
Mailing Address - Country:US
Mailing Address - Phone:803-370-8445
Mailing Address - Fax:
Practice Address - Street 1:269 HORIZON CIR
Practice Address - Street 2:
Practice Address - City:ROCK HILL
Practice Address - State:SC
Practice Address - Zip Code:29732-7628
Practice Address - Country:US
Practice Address - Phone:803-370-8445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-29
Last Update Date:2009-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC6458171W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor