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General NPI Number Information
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NPI Number | 1588667208
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Entity Type | Organization
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Legal Business Name | BRADFORD PLACE SURGERY AND LASER CENTER, LLC
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Dates
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Enumeration Date | 05/27/2005
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Last Update Date | 10/31/2025
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Provider Practice Location Address
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Address Line | 1531 E BRADFORD PARKWAY STE 120
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City | SPRINGFIELD
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State | MO
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Zip | 65804-6539
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Country | US
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Telephone | 417-886-3900
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Fax | 417-886-0094
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Provider Business Mailing Address
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Address Line | 1531 E BRADFORD PKWY STE 100
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City | SPRINGFIELD
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State | MO
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Zip | 65804-6539
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Country | US
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Telephone | 417-886-3900
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Fax | 417-823-2894
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Authorized Official
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Title or Position | CREDENTIALING
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Name | JENNIFER L WYNN
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Credential |
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Telephone | 417-823-2838
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QA1903X
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Taxonomy Name | Ambulatory Surgical Clinic/Center
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License Number | 118.6
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License Number State | MO
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