Provider Demographics
NPI:1205309028
Name:INGRAM, BRADFORD
Entity type:Individual
Prefix:
First Name:BRADFORD
Middle Name:
Last Name:INGRAM
Suffix:
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 1:1800 SAGER RD
Mailing Address - Street 2:
Mailing Address - City:ROCKDALE
Mailing Address - State:TX
Mailing Address - Zip Code:76567-2060
Mailing Address - Country:US
Mailing Address - Phone:512-689-1364
Mailing Address - Fax:
Practice Address - Street 1:1800 SAGER RD
Practice Address - Street 2:
Practice Address - City:ROCKDALE
Practice Address - State:TX
Practice Address - Zip Code:76567-2060
Practice Address - Country:US
Practice Address - Phone:512-689-1364
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX313179164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse