Healthcare Provider Details

I. General information

NPI: 1194569855
Provider Name (Legal Business Name): BRADFORD RIVER BEND, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/19/2024
Last Update Date: 02/23/2026
Certification Date: 02/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 HIGHWAY 90
GAUTIER MS
39553-5705
US

IV. Provider business mailing address

1 PERIMETER PARK S STE 200
BIRMINGHAM AL
35243-2327
US

V. Phone/Fax

Practice location:
  • Phone: 601-791-5135
  • Fax:
Mailing address:
  • Phone: 205-251-7753
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number
License Number State

VIII. Authorized Official

Name: MARK EDWARDS
Title or Position: CFO
Credential:
Phone: 205-244-8112