1427346295 NPI number — ROCKATONIA BRADLEY

Table of content: ROCKATONIA BRADLEY (NPI 1427346295)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427346295 NPI number — ROCKATONIA BRADLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
ROCKATONIA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BATTS
Provider Other First Name:
ROCKATONIA
Provider Other Middle Name:
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
OD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1427346295
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
700 BARRINGTON DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FERNANDINA BEACH
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32034-0916
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
270-339-6179
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1523 SADLER RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FERNANDINA BEACH
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32034-4467
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
270-277-2779
Provider Business Practice Location Address Fax Number:
270-277-2779
Provider Enumeration Date:
07/14/2011

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: 152W00000X , with the licence number:  1851DT , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 152W00000X , with the licence number: 5319 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000000725449 . This is a "ANTHEM" identifier , issued by the state of ( KY ) . This identifiers is of the category "OTHER".
  • Identifier: 7100172600 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".