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NPI Code Detail

MEDICARE: RONNIE JOE BRADLEY LCAS

MEDICARE: RONNIE JOE BRADLEY LCAS
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1101YA0400XAddiction (Substance Use Disorder) Counselor8300412NC

General Provider Information

NPI Number : 1376731158
Entity Type Code : Individual
Provider Name (Legal Business Name) : RONNIE JOE BRADLEY LCAS
Provider Business Mailing Address
First Line : 145 REMOUNT RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28203-5013
Country : US
Telephone Number : 704-332-9001
Fax Number : 704-295-4937
Provider Business Practice Location Address
First Line : 145 REMOUNT RD
Second Line :
City : CHARLOTTE
State : NC
Zip : 28203-5013
Country : US
Telephone Number : 704-332-9001
Fax Number : 704-295-4937
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/05/2007
Last Update Date : 10/06/2007

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