Provider Demographics
NPI:1043286149
Name:DOVER, LEE BRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:BRENT
Last Name:DOVER
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 1:711 MIDWAY CRST
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-4335
Mailing Address - Country:US
Mailing Address - Phone:501-337-6688
Mailing Address - Fax:
Practice Address - Street 1:703 US HIGHWAY 90 E
Practice Address - Street 2:SUITE 107
Practice Address - City:CASTROVILLE
Practice Address - State:TX
Practice Address - Zip Code:78009-5246
Practice Address - Country:US
Practice Address - Phone:830-931-2211
Practice Address - Fax:830-538-3778
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-27
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR1507111N00000X
TX12929111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5U484OtherBCBS
AR7511063OtherAETNA
AR154829718Medicaid
AR710830330OtherFEDERAL ID#
ARP00128953OtherRAILROAD MEDICARE
AR5U484Medicare ID - Type Unspecified
AR154829718Medicaid