1275517765 NPI number — MR. BRADLEY JAMES NUCKELS

Table of content: MR. BRADLEY JAMES NUCKELS (NPI 1275517765)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275517765 NPI number — MR. BRADLEY JAMES NUCKELS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NUCKELS
Provider First Name:
BRADLEY
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
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:
1275517765
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1070 OLD NATIONAL PIKE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREDERICKTOWN
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15333-2114
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-632-6801
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1152 WOOD ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CALIFORNIA
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
15419-1260
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
724-938-2099
Provider Business Practice Location Address Fax Number:
724-938-3221
Provider Enumeration Date:
11/30/2005

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: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1007288440098 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 328834D024298 . This is a "VALUE BEHAVIORAL HEALTH" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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