=====================================================
General NPI Number Information
=====================================================
NPI Number | 1780669960
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY OF BRADFORD
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2005
-----------------------------------------------------
Last Update Date | 03/04/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 24 KENNEDY ST
-----------------------------------------------------
City | BRADFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16701-6508
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-362-3887
-----------------------------------------------------
Fax | 814-368-3335
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 24 KENNEDY ST
-----------------------------------------------------
City | BRADFORD
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 16701-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 814-362-3887
-----------------------------------------------------
Fax | 814-368-3335
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CITY ADMINISTRATOR
-----------------------------------------------------
Name | MRS. TERI CANNON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 814-362-3887
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3416L0300X
-----------------------------------------------------
Taxonomy Name | Land Ambulance
-----------------------------------------------------
License Number | 04055
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------