Provider Demographics
NPI:1902157712
Name:BRADLEY FREE CLINIC OF ROANOKE VALLEY
Entity Type:Organization
Organization Name:BRADLEY FREE CLINIC OF ROANOKE VALLEY
Other - Org Name:BRADLEY FREE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHARMACIST IN CHARGE
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:BLACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-344-5156
Mailing Address - Street 1:1240 3RD ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24016-4612
Mailing Address - Country:US
Mailing Address - Phone:540-344-5156
Mailing Address - Fax:540-777-0726
Practice Address - Street 1:1240 3RD ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24016-4612
Practice Address - Country:US
Practice Address - Phone:540-344-5156
Practice Address - Fax:540-777-0726
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-20
Last Update Date:2021-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QP2300X, 3336C0003X
VA0201002648333600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No333600000XSuppliersPharmacy
No3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
2164384OtherPK