Provider Demographics
NPI:1992193072
Name:BRAGG, BENJAMIN KEVIN
Entity Type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:KEVIN
Last Name:BRAGG
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 1:70 WESTSIDE DR
Mailing Address - Street 2:APT# 201
Mailing Address - City:CULLOWHEE
Mailing Address - State:NC
Mailing Address - Zip Code:28723-1080
Mailing Address - Country:US
Mailing Address - Phone:865-368-0054
Mailing Address - Fax:
Practice Address - Street 1:70 WESTSIDE DR
Practice Address - Street 2:APT# 201
Practice Address - City:CULLOWHEE
Practice Address - State:NC
Practice Address - Zip Code:28723-1080
Practice Address - Country:US
Practice Address - Phone:865-368-0054
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-12-24
Last Update Date:2014-12-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer