1093301400 NPI number — ODESSA RENE BRADLEY HOMEHEALTH

Table of content: ODESSA RENE BRADLEY HOMEHEALTH (NPI 1093301400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093301400 NPI number — ODESSA RENE BRADLEY HOMEHEALTH

Organization/Personal Information

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

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BRADLEY
Provider Other First Name:
ODESSA
Provider Other Middle Name:
RENE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1093301400
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/28/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
601 US HIGHWAY 278 BYP E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PIEDMONT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36272-1457
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-499-3765
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 US HIGHWAY 278 BYP E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PIEDMONT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36272-1457
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-499-3765
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/19/2020

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: 251E00000X , with the licence number:  20213979 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 374U00000X , with the licence number: 20213537 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251E00000X , with the licence number: 4179 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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