Provider Demographics
NPI:1154583946
Name:BRADLEY BAY HEALTH CENTER
Entity type:Organization
Organization Name:BRADLEY BAY HEALTH CENTER
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:O'NEILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:440-327-9777
Mailing Address - Street 1:605 BRADLEY RD
Mailing Address - Street 2:
Mailing Address - City:BAY VILLAGE
Mailing Address - State:OH
Mailing Address - Zip Code:44140-1670
Mailing Address - Country:US
Mailing Address - Phone:440-871-3474
Mailing Address - Fax:
Practice Address - Street 1:605 BRADLEY RD
Practice Address - Street 2:
Practice Address - City:BAY VILLAGE
Practice Address - State:OH
Practice Address - Zip Code:44140-1670
Practice Address - Country:US
Practice Address - Phone:440-871-3474
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:O'NEILL MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-07-02
Last Update Date:2008-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36D0339064291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory