Provider Demographics
NPI:1104290170
Name:BRAUNECKER, ADAM JOSEPH
Entity type:Individual
Prefix:
First Name:ADAM
Middle Name:JOSEPH
Last Name:BRAUNECKER
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 1:3309 COLCHESTER CIR
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-8210
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3355 E 550S
Practice Address - Street 2:
Practice Address - City:HUNTINGBURG
Practice Address - State:IN
Practice Address - Zip Code:47542-9552
Practice Address - Country:US
Practice Address - Phone:812-639-7894
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-13
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
TN22432255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program