Provider Demographics
NPI:1922006634
Name:BRODNAX, SCOTT WALTER (CHIROPRACTOR)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WALTER
Last Name:BRODNAX
Suffix:
Gender:M
Credentials:CHIROPRACTOR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:CLOVER
Mailing Address - State:SC
Mailing Address - Zip Code:29710-1008
Mailing Address - Country:US
Mailing Address - Phone:803-222-2323
Mailing Address - Fax:
Practice Address - Street 1:225 CHURCH ST
Practice Address - Street 2:
Practice Address - City:CLOVER
Practice Address - State:SC
Practice Address - Zip Code:29710-1008
Practice Address - Country:US
Practice Address - Phone:803-222-2323
Practice Address - Fax:803-222-2323
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC842111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCT23763Medicare UPIN
SCT237630281Medicare PIN