Basic Information
| Provider Information | |||||||||
| NPI: | 1467056036 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADFORD | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | EARL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 850 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 E FOOTHILL BLVD | ||||||||
| Address2: | |||||||||
| City: | RIALTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923765230 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9098734409 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2020 | ||||||||
| LastUpdateDate: | 03/04/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 101Y00000X | Y | Behavioral Health & Social Service Providers | Counselor |
No ID Information.