Provider Demographics
NPI:1508967340
Name:PONCHOT, BRYANT LANE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:LANE
Last Name:PONCHOT
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 1:4625 S EMERSON AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46203-5972
Mailing Address - Country:US
Mailing Address - Phone:317-522-2303
Mailing Address - Fax:317-522-2304
Practice Address - Street 1:8258 ROCKVILLE RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46214-3113
Practice Address - Country:US
Practice Address - Phone:317-429-5400
Practice Address - Fax:317-429-5401
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2013-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002296A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor