Provider Demographics
NPI:1346239290
Name:HENRY, BRIAN KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:KEITH
Last Name:HENRY
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 1:8820 GOODMAN RD
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-2204
Mailing Address - Country:US
Mailing Address - Phone:662-890-5454
Mailing Address - Fax:662-893-8343
Practice Address - Street 1:8820 GOODMAN RD
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654-2204
Practice Address - Country:US
Practice Address - Phone:662-890-5454
Practice Address - Fax:662-893-8343
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-13
Last Update Date:2011-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS965111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS5455686OtherAETNA
6241720001OtherCIGNA GOVERNMENT SERVICES
TN4433003OtherUNITED HEALTHCARE
TN3149677OtherB/C B/S OF TN
MS6332775OtherCIGNA
MS4430072OtherUNITED HEALTHCARE
MS6332775OtherCIGNA
MS20-8030743OtherTAX ID NUMBER
MS350000257Medicare ID - Type UnspecifiedMEDICARE
MS$$$$$$$$$BOtherB/C B/S OF MS
MS20-8030743OtherTAX ID NUMBER
TN3149677OtherB/C B/S OF TN