Provider Demographics
NPI:1629803754
Name:LARISA BRADFORD LLC
Entity type:Organization
Organization Name:LARISA BRADFORD LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MEDICAL DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:
Authorized Official - Last Name:RUSSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:404-808-6071
Mailing Address - Street 1:808 MAIN ST SW
Mailing Address - Street 2:
Mailing Address - City:GAINESVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30501-4472
Mailing Address - Country:US
Mailing Address - Phone:404-808-6071
Mailing Address - Fax:
Practice Address - Street 1:808 MAIN ST SW
Practice Address - Street 2:
Practice Address - City:GAINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:30501-4472
Practice Address - Country:US
Practice Address - Phone:404-808-6071
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-06
Last Update Date:2025-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty