Provider Demographics
NPI:1306186697
Name:MALLORY, BRIAN SCOTT (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:SCOTT
Last Name:MALLORY
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 1:467 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:WV
Mailing Address - Zip Code:25130-2200
Mailing Address - Country:US
Mailing Address - Phone:304-369-9500
Mailing Address - Fax:304-369-7978
Practice Address - Street 1:467 MAIN ST
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WV
Practice Address - Zip Code:25130-2200
Practice Address - Country:US
Practice Address - Phone:304-369-9500
Practice Address - Fax:304-369-7978
Is Sole Proprietor?:No
Enumeration Date:2013-02-22
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV953111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor