Healthcare Provider Details

I. General information

NPI: 1619396249
Provider Name (Legal Business Name): BRADLEY SCOTT DALLING CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2014
Last Update Date: 05/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 EAST BLVD
ELKHART IN
46514-2483
US

IV. Provider business mailing address

1828 S MILLENIUM WAY
MERIDIAN ID
83642-5036
US

V. Phone/Fax

Practice location:
  • Phone: 801-822-2011
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number101872
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: