Healthcare Provider Details

I. General information

NPI: 1689228504
Provider Name (Legal Business Name): JOSHUA DAVID BRADFORD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/29/2019
Last Update Date: 07/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3912 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

IV. Provider business mailing address

3912 JUAN TABO BLVD NE
ALBUQUERQUE NM
87111-3971
US

V. Phone/Fax

Practice location:
  • Phone: 505-298-1558
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: