Healthcare Provider Details

I. General information

NPI: 1316868706
Provider Name (Legal Business Name): BRADLEY PATTON BROOKER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 PLYMOUTH DR NE STE 101
KEIZER OR
97303-5049
US

IV. Provider business mailing address

1099 WALLER ST SE
SALEM OR
97302-2970
US

V. Phone/Fax

Practice location:
  • Phone: 971-217-8370
  • Fax:
Mailing address:
  • Phone: 505-359-8372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number29712
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: