1861706681 NPI number — MR. BRADLEY KENT LINDSTROM JR. PA

Table of content: MR. BRADLEY KENT LINDSTROM JR. PA (NPI 1861706681)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861706681 NPI number — MR. BRADLEY KENT LINDSTROM JR. PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LINDSTROM
Provider First Name:
BRADLEY
Provider Middle Name:
KENT
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
PA
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861706681
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/06/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1501 S YALE ST
Provider Second Line Business Mailing Address:
STE 150
Provider Business Mailing Address City Name:
FLAGSTAFF
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
86001-7337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
928-527-4325
Provider Business Mailing Address Fax Number:
928-527-4327

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
50 UNION ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ELLSWORTH
Provider Business Practice Location Address State Name:
ME
Provider Business Practice Location Address Postal Code:
04605-1599
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
207-664-5340
Provider Business Practice Location Address Fax Number:
207-664-5338
Provider Enumeration Date:
08/04/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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