Provider Demographics
NPI:1770721425
Name:BRADWELL DIVERSIFIED INC.
Entity type:Organization
Organization Name:BRADWELL DIVERSIFIED INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:ISRAEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALDONADO
Authorized Official - Suffix:
Authorized Official - Credentials:SLP- ASSISTANT
Authorized Official - Phone:956-498-5219
Mailing Address - Street 1:526 W 2ND ST
Mailing Address - Street 2:
Mailing Address - City:MERCEDES
Mailing Address - State:TX
Mailing Address - Zip Code:78570-2602
Mailing Address - Country:US
Mailing Address - Phone:956-230-3301
Mailing Address - Fax:956-391-2825
Practice Address - Street 1:526 W 2ND ST
Practice Address - Street 2:
Practice Address - City:MERCEDES
Practice Address - State:TX
Practice Address - Zip Code:78570-2602
Practice Address - Country:US
Practice Address - Phone:956-230-3301
Practice Address - Fax:956-391-2825
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-02
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX013856251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX218312101Medicaid
TX218312102Medicaid