Healthcare Provider Details

I. General information

NPI: 1568105310
Provider Name (Legal Business Name): RICHARD BRADLEY OGE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2022
Last Update Date: 04/19/2022
Certification Date: 04/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 E WASHINGTON BLVD
PASADENA CA
91107-1446
US

IV. Provider business mailing address

630 N HOLLYWOOD WAY APT 208
BURBANK CA
91505-3172
US

V. Phone/Fax

Practice location:
  • Phone: 626-463-4105
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: