Healthcare Provider Details

I. General information

NPI: 1760224661
Provider Name (Legal Business Name): BRADLEY GAMACHE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/11/2024
Last Update Date: 06/11/2024
Certification Date: 05/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

875 RUE SAINT FRANCOIS ST
FLORISSANT MO
63031-4923
US

IV. Provider business mailing address

5141 PATTISON AVE
SAINT LOUIS MO
63110-2039
US

V. Phone/Fax

Practice location:
  • Phone: 314-839-2400
  • Fax: 314-839-2403
Mailing address:
  • Phone: 314-313-7849
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number2024019005
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: