Healthcare Provider Details

I. General information

NPI: 1972266658
Provider Name (Legal Business Name): CORY BRADISH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2021
Last Update Date: 10/19/2021
Certification Date: 10/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

460 SAINT MICHAELS DR STE 1205
SANTA FE NM
87505-8605
US

IV. Provider business mailing address

460 SAINT MICHAELS DR STE 1205
SANTA FE NM
87505-8605
US

V. Phone/Fax

Practice location:
  • Phone: 505-490-6160
  • Fax:
Mailing address:
  • Phone: 505-490-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number9465
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: