Healthcare Provider Details

I. General information

NPI: 1245575406
Provider Name (Legal Business Name): BRADLEY KEFFER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/29/2012
Last Update Date: 11/29/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 N SILVER ST
T OR C NM
87901-1957
US

IV. Provider business mailing address

1868 EL SEGUNDO TRL
LAS CRUCES NM
88011-4032
US

V. Phone/Fax

Practice location:
  • Phone: 575-894-7855
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number1582
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: