Provider Demographics
NPI:1144411067
Name:SALLEY, BRETT TYSON (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:TYSON
Last Name:SALLEY
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 1:2313 EAST CENTER ST
Mailing Address - Street 2:SUITE A
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-2798
Mailing Address - Country:US
Mailing Address - Phone:423-247-4400
Mailing Address - Fax:423-247-4404
Practice Address - Street 1:2313 EAST CENTER ST
Practice Address - Street 2:SUITE A
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-2798
Practice Address - Country:US
Practice Address - Phone:423-247-4400
Practice Address - Fax:423-247-4404
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-06
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1059111N00000X
WA2724111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3677584Medicaid
3677584Medicare PIN
U54083Medicare UPIN