Provider Demographics
NPI:1306854443
Name:DAVIS, BRIAN KEITH (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:DAVIS
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:PO BOX 3304
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39505-3304
Mailing Address - Country:US
Mailing Address - Phone:228-831-8181
Mailing Address - Fax:228-831-8182
Practice Address - Street 1:12178 HIGHWAY 49 STE F
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-3170
Practice Address - Country:US
Practice Address - Phone:228-831-8181
Practice Address - Fax:228-831-8182
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-04
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS780111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00120377Medicaid
MS5220674OtherAETNA
MS00120377Medicaid
MS350000174Medicare ID - Type Unspecified