Provider Demographics
NPI:1891176715
Name:BRADFORD SCC LLC
Entity Type:Organization
Organization Name:BRADFORD SCC LLC
Other - Org Name:THE BRADFORD REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-252-7600
Mailing Address - Street 1:600 N PEARL ST STE 1050
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75201-7495
Mailing Address - Country:US
Mailing Address - Phone:214-252-7600
Mailing Address - Fax:214-252-7704
Practice Address - Street 1:3050 BAIRD RD
Practice Address - Street 2:
Practice Address - City:SHREVEPORT
Practice Address - State:LA
Practice Address - Zip Code:71118-3818
Practice Address - Country:US
Practice Address - Phone:318-688-1010
Practice Address - Fax:318-688-1099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-16
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA19-5513OtherMEDICARE PART A
LA1516546Medicaid
LA19-5513OtherMEDICARE PART A