Provider Demographics
NPI:1508969411
Name:HOOPER, BRYAN KEITH (DC)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:KEITH
Last Name:HOOPER
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 1:1011 WOODRIDGE LANE
Mailing Address - Street 2:BUILDING 301
Mailing Address - City:WATKINSVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30677-6077
Mailing Address - Country:US
Mailing Address - Phone:706-310-1121
Mailing Address - Fax:706-310-1165
Practice Address - Street 1:1011 WOODRIDGE LANE
Practice Address - Street 2:BUILDING 301
Practice Address - City:WATKINSVILLE
Practice Address - State:GA
Practice Address - Zip Code:30677-6077
Practice Address - Country:US
Practice Address - Phone:706-310-1121
Practice Address - Fax:706-310-1165
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA6752111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA35ZCGRZMedicare ID - Type UnspecifiedCHIROPRACTOR