Healthcare Provider Details

I. General information

NPI: 1760945406
Provider Name (Legal Business Name): BRADLEY RYAN COLLINS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2019
Last Update Date: 04/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1515 SW ARCHER RD
GAINESVILLE FL
32608-1134
US

IV. Provider business mailing address

1329 SW 16TH ST STE 5270
GAINESVILLE FL
32608-1128
US

V. Phone/Fax

Practice location:
  • Phone: 352-733-0800
  • Fax:
Mailing address:
  • Phone: 352-265-5911
  • Fax: 352-265-5606

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: