Provider Demographics
NPI:1972008555
Name:BRADLEY EYECARE LLC
Entity Type:Organization
Organization Name:BRADLEY EYECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROCKATONIA
Authorized Official - Middle Name:
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:270-339-6179
Mailing Address - Street 1:463867 STATE ROAD 200 STE 4
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-3605
Mailing Address - Country:US
Mailing Address - Phone:904-277-7779
Mailing Address - Fax:
Practice Address - Street 1:463867 STATE ROAD 200 STE 4
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3605
Practice Address - Country:US
Practice Address - Phone:904-277-7779
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-27
Last Update Date:2018-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL5319152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty