=====================================================
General NPI Number Information
=====================================================
NPI Number | 1629420526
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRADLEY LINDER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/05/2016
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1442 N 31ST ST
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-3061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-452-5400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1442 N 31ST ST
-----------------------------------------------------
City | SHEBOYGAN
-----------------------------------------------------
State | WI
-----------------------------------------------------
Zip | 53081-3061
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 920-918-3674
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 156FX1800X
-----------------------------------------------------
Taxonomy Name | Optician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------