Provider Demographics
NPI:1891899290
Name:BRADBERRY, JAMES RANDALL JR (ATC, LAT)
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:RANDALL
Last Name:BRADBERRY
Suffix:JR
Gender:M
Credentials:ATC, LAT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 DARWISH DR
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30252-3655
Mailing Address - Country:US
Mailing Address - Phone:678-272-7814
Mailing Address - Fax:
Practice Address - Street 1:2400 HIGHWAY 42 N
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-4738
Practice Address - Country:US
Practice Address - Phone:404-569-2463
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-07
Last Update Date:2008-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0013982255A2300X
2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer