Healthcare Provider Details

I. General information

NPI: 1922006634
Provider Name (Legal Business Name): SCOTT WALTER BRODNAX CHIROPRACTOR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2005
Last Update Date: 10/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 CHURCH ST
CLOVER SC
29710-1008
US

IV. Provider business mailing address

225 CHURCH ST
CLOVER SC
29710-1008
US

V. Phone/Fax

Practice location:
  • Phone: 803-222-2323
  • Fax: 803-222-2323
Mailing address:
  • Phone: 803-222-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number842
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: