Provider Demographics
NPI:1154178853
Name:BRADFORD, CALEB S
Entity type:Individual
Prefix:
First Name:CALEB
Middle Name:S
Last Name:BRADFORD
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13031 MIRAGE RD
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392
Mailing Address - Country:US
Mailing Address - Phone:562-881-0643
Mailing Address - Fax:
Practice Address - Street 1:1926 VIA CTR STE B
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6056
Practice Address - Country:US
Practice Address - Phone:949-474-1493
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-01
Last Update Date:2024-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician