Healthcare Provider Details

I. General information

NPI: 1003802075
Provider Name (Legal Business Name): BRADSHAW MOUNTAIN DIAGNOSTIC LABORATORY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

990 WILLOW CREEK RD
PRESCOTT AZ
86301-1640
US

IV. Provider business mailing address

990 WILLOW CREEK RD
PRESCOTT AZ
86301-1640
US

V. Phone/Fax

Practice location:
  • Phone: 928-778-7823
  • Fax: 928-778-9419
Mailing address:
  • Phone: 928-778-7823
  • Fax: 928-778-9419

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number StateAZ

VIII. Authorized Official

Name: MR. TOM FELLOWS
Title or Position: PRESIDENT
Credential:
Phone: 928-778-7823