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General NPI Number Information
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NPI Number | 1689415911
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Entity Type | Organization
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Legal Business Name | BRADLEY JAY E. PROFESSIONAL CORPORATION
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Dates
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Enumeration Date | 06/03/2024
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Last Update Date | 06/03/2024
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Provider Practice Location Address
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Address Line | 2501 E CHAPMAN AVE UNIT 107-C
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City | FULLERTON
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State | CA
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Zip | 92831-3132
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Country | US
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Telephone | 626-429-0088
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Fax |
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Provider Business Mailing Address
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Address Line | 11278 LOS ALAMITOS BLVD UNIT 830
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City | LOS ALAMITOS
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State | CA
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Zip | 90720-3958
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | JACKSON TEA
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Credential | MD
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Telephone | 626-429-0088
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174400000X
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Taxonomy Name | Specialist
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License Number |
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License Number State |
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