Provider Demographics
NPI:1265732929
Name:BRODHEAD, BENJAMIN RICHARD (LAC)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:RICHARD
Last Name:BRODHEAD
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:MR
Other - First Name:BEN
Other - Middle Name:
Other - Last Name:BRODHEAD
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LAC; MACOM
Mailing Address - Street 1:51 JOHNNY MERCER BLVD STE B2
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31410-4924
Mailing Address - Country:US
Mailing Address - Phone:912-349-2101
Mailing Address - Fax:912-480-9679
Practice Address - Street 1:51 JOHNNY MERCER BLVD STE B2
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31410-4924
Practice Address - Country:US
Practice Address - Phone:912-349-2101
Practice Address - Fax:912-480-9679
Is Sole Proprietor?:No
Enumeration Date:2010-10-28
Last Update Date:2023-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA287171100000X
WAAC60181638171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist