Provider Demographics
NPI:1053630467
Name:BROADUS, BRANDON MATTHEW (DC)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MATTHEW
Last Name:BROADUS
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 1:102 FONTAINBLEAU DR # D1
Mailing Address - Street 2:
Mailing Address - City:MANDEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:70471-6518
Mailing Address - Country:US
Mailing Address - Phone:985-789-1720
Mailing Address - Fax:
Practice Address - Street 1:102 FONTAINBLEAU DR # D1
Practice Address - Street 2:
Practice Address - City:MANDEVILLE
Practice Address - State:LA
Practice Address - Zip Code:70471-6518
Practice Address - Country:US
Practice Address - Phone:985-400-5300
Practice Address - Fax:985-400-5301
Is Sole Proprietor?:Yes
Enumeration Date:2010-05-25
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1535111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor