Provider Demographics
NPI:1861664237
Name:LLEWELLYN, BRIAN KENT (DC)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:KENT
Last Name:LLEWELLYN
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 1:122 S RAWLES STREET
Mailing Address - Street 2:SUITE 112
Mailing Address - City:ROMEO
Mailing Address - State:MI
Mailing Address - Zip Code:48065-5177
Mailing Address - Country:US
Mailing Address - Phone:586-752-6111
Mailing Address - Fax:
Practice Address - Street 1:122 S RAWLES STREET
Practice Address - Street 2:SUITE 112
Practice Address - City:ROMEO
Practice Address - State:MI
Practice Address - Zip Code:48065-5177
Practice Address - Country:US
Practice Address - Phone:586-752-6111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-26
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2301006643111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950E05220OtherBLUE CROSS BLUE SHIELD
MI0E05220Medicare PIN
MI950E05220OtherBLUE CROSS BLUE SHIELD