Healthcare Provider Details

I. General information

NPI: 1588667208
Provider Name (Legal Business Name): BRADFORD PLACE SURGERY AND LASER CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 10/31/2025
Certification Date: 10/31/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1531 E BRADFORD PARKWAY STE 120
SPRINGFIELD MO
65804-6539
US

IV. Provider business mailing address

1531 E BRADFORD PKWY STE 100
SPRINGFIELD MO
65804-6539
US

V. Phone/Fax

Practice location:
  • Phone: 417-886-3900
  • Fax: 417-886-0094
Mailing address:
  • Phone: 417-886-3900
  • Fax: 417-823-2894

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number118.6
License Number StateMO

VIII. Authorized Official

Name: JENNIFER L WYNN
Title or Position: CREDENTIALING
Credential:
Phone: 417-823-2838