Provider Demographics
NPI:1154767911
Name:BRADWELL DIVERSIFIED
Entity type:Organization
Organization Name:BRADWELL DIVERSIFIED
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GRACIELA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADWELL
Authorized Official - Suffix:
Authorized Official - Credentials:SLP ASSISTANT
Authorized Official - Phone:956-792-4542
Mailing Address - Street 1:27043 BAKER POTTS RD
Mailing Address - Street 2:
Mailing Address - City:HARLINGEN
Mailing Address - State:TX
Mailing Address - Zip Code:78552-3761
Mailing Address - Country:US
Mailing Address - Phone:956-792-4542
Mailing Address - Fax:
Practice Address - Street 1:27043 BAKER POTTS RD
Practice Address - Street 2:
Practice Address - City:HARLINGEN
Practice Address - State:TX
Practice Address - Zip Code:78552-3761
Practice Address - Country:US
Practice Address - Phone:956-792-4542
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-05-20
Last Update Date:2013-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation