1578741898 NPI number — BRADLEY CLEVELAND REHAB SERVICES

Table of content: (NPI 1578741898)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578741898 NPI number — BRADLEY CLEVELAND REHAB SERVICES

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
YOUTH COUNSELING SERVICES
Provider Other Organization Name Type Code:
5
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:
1578741898
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/05/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
423 CENTRAL AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CLEVELAND
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37311-4923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-476-1933
Provider Business Mailing Address Fax Number:
423-559-1848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
423 CENTRAL AVE NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37311-4923
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-476-1933
Provider Business Practice Location Address Fax Number:
423-559-1848
Provider Enumeration Date:
02/08/2008

Additional Information

Authorized Official

Authorized Official Last Name:
VINING
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
KIE
Authorized Official Title or Position:
CHAIRMAN OF BOARD
Authorized Official Telephone Number:
423-476-1933

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , with the licence number:  L214-117-2195 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: LPC0000000694 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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