Provider Demographics
NPI:1750618948
Name:BRADSHAW, ETHEL RUTH
Entity type:Individual
Prefix:MRS
First Name:ETHEL
Middle Name:RUTH
Last Name:BRADSHAW
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 103
Mailing Address - Street 2:
Mailing Address - City:UNION GROVE
Mailing Address - State:NC
Mailing Address - Zip Code:28689-0103
Mailing Address - Country:US
Mailing Address - Phone:704-539-4445
Mailing Address - Fax:704-539-4663
Practice Address - Street 1:1892 WEST MEMORIAL HWY
Practice Address - Street 2:
Practice Address - City:UNION GROVE
Practice Address - State:NC
Practice Address - Zip Code:28689-9049
Practice Address - Country:US
Practice Address - Phone:704-539-4445
Practice Address - Fax:704-539-4663
Is Sole Proprietor?:No
Enumeration Date:2009-11-09
Last Update Date:2009-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7703861Medicaid