Provider Demographics
NPI:1285707430
Name:BRADDOCK, KARROL (PT)
Entity type:Individual
Prefix:
First Name:KARROL
Middle Name:
Last Name:BRADDOCK
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 307
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84011-0307
Mailing Address - Country:US
Mailing Address - Phone:888-700-6907
Mailing Address - Fax:801-294-6917
Practice Address - Street 1:1525 S SOUTH ST
Practice Address - Street 2:
Practice Address - City:GLOBE
Practice Address - State:AZ
Practice Address - Zip Code:85501-1475
Practice Address - Country:US
Practice Address - Phone:928-425-0444
Practice Address - Fax:928-402-1828
Is Sole Proprietor?:No
Enumeration Date:2006-11-16
Last Update Date:2007-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3268225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ113198Medicare PIN