| Larisa Bradford Llc | |
|
808 Main St Sw Gainesville GA 30501-4472 | |
| (404) 808-6071 | |
| Not Available |
| Full Name | Larisa Bradford Llc |
|---|---|
| Speciality | Family Medicine |
| Location | 808 Main St Sw, Gainesville, Georgia |
| Authorized Official Name and Position | Larisa Russell (OWNER/MEDICAL DOCTOR) |
| Authorized Official Contact | 4048086071 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Larisa Bradford Llc 808 Main St Sw Gainesville GA 30501-4472 Ph: (404) 808-6071 | Larisa Bradford Llc 808 Main St Sw Gainesville GA 30501-4472 Ph: (404) 808-6071 |
| NPI Number | 1629803754 |
|---|---|
| Provider Enumeration Date | 09/06/2024 |
| Last Update Date | 01/23/2025 |
| Medicare PECOS PAC ID | 2668982059 |
|---|---|
| Medicare Enrollment ID | O20250605002588 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1629803754 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 207Q00000X | Family Medicine | (* (Not Available)) | Primary |
| Provider Name | Larisa V. Russell |
|---|---|
| Provider Type | Practitioner - Family Practice |
| Provider Identifiers | NPI Number: 1104812494 PECOS PAC ID: 5698707461 Enrollment ID: I20250605002673 |
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