Provider Demographics
NPI:1063874568
Name:BRADFORD RECOVERY CENTER
Entity type:Organization
Organization Name:BRADFORD RECOVERY CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:K
Authorized Official - Last Name:LEIB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-537-6035
Mailing Address - Street 1:64 SCHOOL ST
Mailing Address - Street 2:
Mailing Address - City:MILLERTON
Mailing Address - State:PA
Mailing Address - Zip Code:16936-7768
Mailing Address - Country:US
Mailing Address - Phone:570-537-6035
Mailing Address - Fax:570-537-6038
Practice Address - Street 1:64 SCHOOL ST
Practice Address - Street 2:
Practice Address - City:MILLERTON
Practice Address - State:PA
Practice Address - Zip Code:16936-7768
Practice Address - Country:US
Practice Address - Phone:570-537-6035
Practice Address - Fax:570-537-6038
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-23
Last Update Date:2019-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA597030324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility