Healthcare Provider Details

I. General information

NPI: 1265760029
Provider Name (Legal Business Name): BRIAN MICHAEL BRADLEY MS, ATC, LAT, CSCS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/05/2009
Last Update Date: 07/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

745 ORIENTA AVE SUITE 1015
ALTAMONTE SPRINGS FL
32701-5619
US

IV. Provider business mailing address

745 ORIENTA AVE SUITE 1015
ALTAMONTE SPRINGS FL
32701-5619
US

V. Phone/Fax

Practice location:
  • Phone: 407-332-7816
  • Fax:
Mailing address:
  • Phone: 407-332-7816
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAL2522
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1998
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: