Healthcare Provider Details

I. General information

NPI: 1669030284
Provider Name (Legal Business Name): THOMAS MARTIN BRADLEY HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/29/2019
Last Update Date: 05/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

909 COLONIAL DR
ST AUGUSTINE FL
32086-7966
US

IV. Provider business mailing address

909 COLONIAL DR
ST AUGUSTINE FL
32086-7966
US

V. Phone/Fax

Practice location:
  • Phone: 904-377-6115
  • Fax:
Mailing address:
  • Phone: 904-377-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License NumberAS3361
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: