Healthcare Provider Details

I. General information

NPI: 1447875794
Provider Name (Legal Business Name): BRADLEY ROYER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/12/2020
Last Update Date: 06/12/2020
Certification Date: 06/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14075R S 1ST ST
MILAN TN
38358-6195
US

IV. Provider business mailing address

1804 HIGHWAY 45 BYP STE 604
JACKSON TN
38305-4403
US

V. Phone/Fax

Practice location:
  • Phone: 731-686-2010
  • Fax: 731-686-3798
Mailing address:
  • Phone: 731-660-8781
  • Fax: 731-660-8739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number1964
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: