Basic Information
| Provider Information | |||||||||
| NPI: | 1851817233 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BRADLEY | ||||||||
| FirstName: | ANTHONY | ||||||||
| MiddleName: | CHARLES | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | HIS | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 528 N PALM AVE | ||||||||
| Address2: | |||||||||
| City: | ONTARIO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917623218 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9099869635 | ||||||||
| FaxNumber: | 9093915873 | ||||||||
| Practice Location | |||||||||
| Address1: | 1600 E FLORIDA AVE STE 312&314 | ||||||||
| Address2: | |||||||||
| City: | HEMET | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925448643 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9516529143 | ||||||||
| FaxNumber: | 9519296653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/17/2017 | ||||||||
| LastUpdateDate: | 12/07/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
No ID Information.