Basic Information
| Provider Information | |||||||||
| NPI: | 1912219643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | BRADLEY COUNTY MEDICAL CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 E 10TH ST | ||||||||
| Address2: | |||||||||
| City: | WACONIA | ||||||||
| State: | MN | ||||||||
| PostalCode: | 553874552 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9524429770 | ||||||||
| FaxNumber: | 9524423621 | ||||||||
| Practice Location | |||||||||
| Address1: | 404 S BRADLEY ST | ||||||||
| Address2: | |||||||||
| City: | WARREN | ||||||||
| State: | AR | ||||||||
| PostalCode: | 716713459 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8702263731 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/10/2010 | ||||||||
| LastUpdateDate: | 11/11/2022 | ||||||||
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| AuthorizedOfficialLastName: | HUITT | ||||||||
| AuthorizedOfficialFirstName: | LESLIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/CFO | ||||||||
| AuthorizedOfficialTelephone: | 8702264301 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | 11/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | AR | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.