Provider Demographics
NPI:1770646259
Name:BRADDON, MITCHELL (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:
Last Name:BRADDON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1170 ALPHARETTA ST
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30075-3631
Mailing Address - Country:US
Mailing Address - Phone:770-998-7774
Mailing Address - Fax:770-998-8814
Practice Address - Street 1:1170 ALPHARETTA ST
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30075-3631
Practice Address - Country:US
Practice Address - Phone:770-998-7774
Practice Address - Fax:770-998-8814
Is Sole Proprietor?:No
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR004968111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA543858OtherBLUE CROSS BLUE SHIELD
GA543858OtherBLUE CROSS BLUE SHIELD