Provider Demographics
NPI:1740022110
Name:BRADFORDT, ELAINE LEATRICE
Entity type:Individual
Prefix:
First Name:ELAINE
Middle Name:LEATRICE
Last Name:BRADFORDT
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:INFINITE
Other - Middle Name:CRUISE
Other - Last Name:CONCIEGRE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:2884 NOBLE RD
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND HTS
Mailing Address - State:OH
Mailing Address - Zip Code:44121-2231
Mailing Address - Country:US
Mailing Address - Phone:216-770-4290
Mailing Address - Fax:
Practice Address - Street 1:2884 NOBLE RD
Practice Address - Street 2:
Practice Address - City:CLEVELAND HTS
Practice Address - State:OH
Practice Address - Zip Code:44121-2231
Practice Address - Country:US
Practice Address - Phone:216-770-4290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-07
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRM783349347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle