Provider Demographics
NPI:1689922734
Name:FORTINBERRY, BRANDON SLOANE (DC)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:SLOANE
Last Name:FORTINBERRY
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 1:1029 HIGHWAY 51 STE F2
Mailing Address - Street 2:
Mailing Address - City:MADISON
Mailing Address - State:MS
Mailing Address - Zip Code:39110-7648
Mailing Address - Country:US
Mailing Address - Phone:601-605-0309
Mailing Address - Fax:
Practice Address - Street 1:1029 HIGHWAY 51 STE F2
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:MS
Practice Address - Zip Code:39110-7648
Practice Address - Country:US
Practice Address - Phone:601-605-0309
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2012-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1189111N00000X
MS721111NR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NR0400XChiropractic ProvidersChiropractorRehabilitation