Provider Demographics
NPI:1457750135
Name:BRADLEY IN HOME SERVICE, LLC
Entity Type:Organization
Organization Name:BRADLEY IN HOME SERVICE, LLC
Other - Org Name:BRADLEY INHOME SERVICE, LLC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MAIRIO
Authorized Official - Middle Name:RENWICK
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-833-3050
Mailing Address - Street 1:141 N MERAMEC AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:MO
Mailing Address - Zip Code:63105-3750
Mailing Address - Country:US
Mailing Address - Phone:314-791-0109
Mailing Address - Fax:314-833-3058
Practice Address - Street 1:141 N MERAMEC AVE STE 300
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:MO
Practice Address - Zip Code:63105-3750
Practice Address - Country:US
Practice Address - Phone:314-791-0109
Practice Address - Fax:314-833-3058
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-19
Last Update Date:2024-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1457750135Medicaid