Healthcare Provider Details

I. General information

NPI: 1982549408
Provider Name (Legal Business Name): BRADLEY BUTCHER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2026
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1585 3RD ST BLDG 285
FORT POLK LA
71459-5102
US

IV. Provider business mailing address

347 WATSON RD APT 11
LEESVILLE LA
71446-3076
US

V. Phone/Fax

Practice location:
  • Phone: 726-780-2175
  • Fax:
Mailing address:
  • Phone: 337-208-2097
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: