Provider Demographics
NPI:1164475935
Name:PONDER, BRAXTON M (LAC)
Entity Type:Individual
Prefix:MR
First Name:BRAXTON
Middle Name:M
Last Name:PONDER
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 TWINCREEK CIR
Mailing Address - Street 2:
Mailing Address - City:PAGOSA SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:81147-8335
Mailing Address - Country:US
Mailing Address - Phone:970-264-1172
Mailing Address - Fax:
Practice Address - Street 1:475 LEWIS STREET
Practice Address - Street 2:SUITE 207
Practice Address - City:PAGOSA SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:81147-0232
Practice Address - Country:US
Practice Address - Phone:970-264-1172
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COACU-1125171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist