Provider Demographics
NPI:1851944607
Name:WATERS, BRIAN KEITH (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KEITH
Last Name:WATERS
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 1:6257 OLD AXSON RD
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31535-3429
Mailing Address - Country:US
Mailing Address - Phone:912-314-3023
Mailing Address - Fax:
Practice Address - Street 1:403 WARD ST W
Practice Address - Street 2:
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-3505
Practice Address - Country:US
Practice Address - Phone:912-260-0005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-22
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008092111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor