Healthcare Provider Details

I. General information

NPI: 1255018099
Provider Name (Legal Business Name): BRADLEY GAMBRELL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16587 ENTERPRISE DR STE E
THREE RIVERS MI
49093-7902
US

IV. Provider business mailing address

16587 ENTERPRISE DR STE E
THREE RIVERS MI
49093-7902
US

V. Phone/Fax

Practice location:
  • Phone: 213-864-1870
  • Fax:
Mailing address:
  • Phone: 213-864-1870
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: