Provider Demographics
NPI:1588657357
Name:PORTER, BRENT (DC)
Entity Type:Individual
Prefix:DR
First Name:BRENT
Middle Name:
Last Name:PORTER
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 1:115 NORTH 4TH ST.
Mailing Address - Street 2:
Mailing Address - City:LEOTI
Mailing Address - State:KS
Mailing Address - Zip Code:67861
Mailing Address - Country:US
Mailing Address - Phone:620-375-5222
Mailing Address - Fax:620-375-5223
Practice Address - Street 1:115 N. 4TH ST.
Practice Address - Street 2:
Practice Address - City:LEOTI
Practice Address - State:KS
Practice Address - Zip Code:67861
Practice Address - Country:US
Practice Address - Phone:620-375-5222
Practice Address - Fax:620-375-5223
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-26
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS4805111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSU92052Medicare UPIN
KS060983Medicare ID - Type UnspecifiedPROVIDER NUMBER