Provider Demographics
NPI:1295799351
Name:LAROSA, BRADLEY (ATC)
Entity type:Individual
Prefix:
First Name:BRADLEY
Middle Name:
Last Name:LAROSA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1110 RUCKER LN
Mailing Address - Street 2:
Mailing Address - City:STAUNTON
Mailing Address - State:IL
Mailing Address - Zip Code:62088-4175
Mailing Address - Country:US
Mailing Address - Phone:618-635-3527
Mailing Address - Fax:
Practice Address - Street 1:955 E TRAFFICWAY ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65802-3671
Practice Address - Country:US
Practice Address - Phone:618-830-7511
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO200030275592255A2300X
IL960018702255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer