Provider Demographics
NPI:1902975121
Name:BRADLEY V FELLOWS INC
Entity type:Organization
Organization Name:BRADLEY V FELLOWS INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:V
Authorized Official - Last Name:FELLOWS
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:801-566-4119
Mailing Address - Street 1:9035 SOUTH 1300 EAST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094
Mailing Address - Country:US
Mailing Address - Phone:801-566-4119
Mailing Address - Fax:801-568-3844
Practice Address - Street 1:9035 SOUTH 1300 EAST
Practice Address - Street 2:100
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094
Practice Address - Country:US
Practice Address - Phone:801-619-9494
Practice Address - Fax:801-619-9546
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT1135088908152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT524900806001Medicaid
T78123Medicare UPIN