Healthcare Provider Details

I. General information

NPI: 1194835397
Provider Name (Legal Business Name): ELLEN ROBERTA BRADLEY OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MRS. ELLEN GARFIELD

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 12/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11714 S FEDERAL HWY
HOBE SOUND FL
33455-5303
US

IV. Provider business mailing address

11714 SE FEDERAL HWY
HOBE SOUND FL
33455-5303
US

V. Phone/Fax

Practice location:
  • Phone: 772-546-4116
  • Fax: 772-546-5172
Mailing address:
  • Phone: 772-546-4116
  • Fax: 772-546-5172

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC1904
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number061001178
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberONO4493
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: