Provider Demographics
NPI:1811196413
Name:BROGDON, DAVID GRANT (DC)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:GRANT
Last Name:BROGDON
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 1:1471 N MACK SMITH RD
Mailing Address - Street 2:
Mailing Address - City:EAST RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37412-3947
Mailing Address - Country:US
Mailing Address - Phone:423-485-8480
Mailing Address - Fax:423-485-8481
Practice Address - Street 1:1471 N MACK SMITH RD
Practice Address - Street 2:
Practice Address - City:EAST RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37412-3947
Practice Address - Country:US
Practice Address - Phone:423-485-8480
Practice Address - Fax:423-485-8481
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2007-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1330111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNU65006Medicare UPIN