Provider Demographics
NPI:1083194195
Name:CARROLL, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1131 QUEENSBOROUGH BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-5430
Mailing Address - Country:US
Mailing Address - Phone:843-972-3174
Mailing Address - Fax:
Practice Address - Street 1:1131 QUEENSBOROUGH BLVD STE 101
Practice Address - Street 2:
Practice Address - City:MT PLEASANT
Practice Address - State:SC
Practice Address - Zip Code:29464-5430
Practice Address - Country:US
Practice Address - Phone:843-972-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-17
Last Update Date:2018-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4359111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor