1407557861 NPI number — RODRIQUES DEMARIO SANTIL BRADLEY PA

Table of content: RODRIQUES DEMARIO SANTIL BRADLEY PA (NPI 1407557861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407557861 NPI number — RODRIQUES DEMARIO SANTIL BRADLEY PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
RODRIQUES
Provider Middle Name:
DEMARIO SANTIL
Provider Name Prefix Text:
Provider Name Suffix Text:
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:
BRADLEY
Provider Other First Name:
RODRIQUES
Provider Other Middle Name:
DEMARIO SANTIL
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1407557861
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/13/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1811 N WESTERN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90027-3403
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-616-7141
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1811 N WESTERN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90027-3403
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-533-5626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/13/2023

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 , with the licence number:  62466 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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