Healthcare Provider Details

I. General information

NPI: 1922571801
Provider Name (Legal Business Name): BILL MACK BRADLEY JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/03/2019
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 E TRAVIS BLVD
FAIRFIELD CA
94533-3958
US

IV. Provider business mailing address

345 E TRAVIS BLVD
FAIRFIELD CA
94533-3958
US

V. Phone/Fax

Practice location:
  • Phone: 510-850-7283
  • Fax: 510-569-4589
Mailing address:
  • Phone: 510-850-7283
  • Fax: 510-569-4589

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: