Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN1001X | Nutrition | CH-3690 | FL |
NPI | 1518088913 |
---|---|
Provider Name | Dr. Barry J. Bradley |
First Address | Lake Mary, FL 32746 |
Second Address | Lake Mary, FL 32746-1641 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 03/04/2007 |
Last Update Date | 08/07/2007 |