Healthcare Provider Details

I. General information

NPI: 1174419006
Provider Name (Legal Business Name): BRADEN ARCHER BRUNNHOELZL LMT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/16/2025
Last Update Date: 06/16/2025
Certification Date: 06/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12812 OLD GLENN HWY STE A8
EAGLE RIVER AK
99577-7003
US

IV. Provider business mailing address

11231 E AMFAY DR
PALMER AK
99645-8879
US

V. Phone/Fax

Practice location:
  • Phone: 907-696-8020
  • Fax:
Mailing address:
  • Phone: 907-355-2762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number240459
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: