1508340357 NPI number — KAYCE C BRADLEY

Table of content: KAYCE C BRADLEY (NPI 1508340357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508340357 NPI number — KAYCE C BRADLEY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRADLEY
Provider First Name:
KAYCE
Provider Middle Name:
C
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:
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:
1508340357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/12/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
911 W 2840 S
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NIBLEY
Provider Business Mailing Address State Name:
UT
Provider Business Mailing Address Postal Code:
84321-6522
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
801-388-3981
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
75 W 100 S STE 220
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LOGAN
Provider Business Practice Location Address State Name:
UT
Provider Business Practice Location Address Postal Code:
84321-5842
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
435-554-1119
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
09/18/2018

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: 104100000X , with the licence number:  11587627-3502 , registered in the state of UT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 990177601002 , issued by the state of ( UT ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com