Healthcare Provider Details

I. General information

NPI: 1922282110
Provider Name (Legal Business Name): BRADLEY SCOTT FOWLER P.T.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 MILLER ST. COMPREHAB PLAZA
WINSTON-SALEM NC
27103
US

IV. Provider business mailing address

5013 MEREWORTH CT
WINSTON SALEM NC
27104-2527
US

V. Phone/Fax

Practice location:
  • Phone: 336-716-8113
  • Fax:
Mailing address:
  • Phone: 336-765-7552
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2251S0007X
TaxonomySports Physical Therapist
License Number8163
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: