Provider Demographics
NPI:1891382453
Name:BRADLEY, JOHN III
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:BRADLEY
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3607 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-4256
Mailing Address - Country:US
Mailing Address - Phone:313-729-4019
Mailing Address - Fax:
Practice Address - Street 1:3607 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-4256
Practice Address - Country:US
Practice Address - Phone:313-729-4019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-29
Last Update Date:2020-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health