MEDICARE: BRADLEY JAMES SMITH PT

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
1	225100000X	Physical Therapist	PT22821	CA

General Provider Information

NPI Number	:	1407812019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	BRADLEY JAMES SMITH PT

Provider Business Mailing Address
First Line	:	PO BOX 551
Second Line	:
City	:	KELSEYVILLE
State	:	CA
Zip	:	95451-0551
Country	:	US
Telephone Number	:	707-279-0881
Fax Number	:	707-279-0887

Provider Business Practice Location Address
First Line	:	5289 STATE ST
Second Line	:
City	:	KELSEYVILLE
State	:	CA
Zip	:	95451
Country	:	US
Telephone Number	:	707-279-0881
Fax Number	:	707-279-0887

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/22/2006
Last Update Date	:	05/25/2010

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