Healthcare Provider Details

I. General information

NPI: 1972352904
Provider Name (Legal Business Name): TAYLOR ANN BRADT OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/13/2024
Last Update Date: 06/20/2024
Certification Date: 06/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 SOUTHGATE STE 5
PENDLETON OR
97801
US

IV. Provider business mailing address

720 NW 12TH ST
PENDLETON OR
97801-1230
US

V. Phone/Fax

Practice location:
  • Phone: 541-203-3159
  • Fax:
Mailing address:
  • Phone: 541-310-1728
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4737
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: