Provider Demographics
NPI:1538257415
Name:BRADLEY EYECARE, P.C.
Entity type:Organization
Organization Name:BRADLEY EYECARE, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JASON
Authorized Official - Middle Name:L
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:701-852-5626
Mailing Address - Street 1:207 MAIN ST S
Mailing Address - Street 2:
Mailing Address - City:MINOT
Mailing Address - State:ND
Mailing Address - Zip Code:58701-3915
Mailing Address - Country:US
Mailing Address - Phone:701-852-5626
Mailing Address - Fax:
Practice Address - Street 1:207 MAIN ST S
Practice Address - Street 2:
Practice Address - City:MINOT
Practice Address - State:ND
Practice Address - Zip Code:58701-3915
Practice Address - Country:US
Practice Address - Phone:701-852-5626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-10
Last Update Date:2018-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ND544152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND01475002OtherBLUE CROSS BLUE SHIELD
ND60632Medicaid
ND01475003OtherVISION SERVICES, INC
ND60632Medicaid
NDN711906Medicare PIN