Provider Demographics
NPI:1922264464
Name:DESHAW, BRENT J (DC)
Entity Type:Individual
Prefix:
First Name:BRENT
Middle Name:J
Last Name:DESHAW
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 1:664 SCRANTON RD
Mailing Address - Street 2:SUITE 222
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31520-1945
Mailing Address - Country:US
Mailing Address - Phone:912-264-2244
Mailing Address - Fax:
Practice Address - Street 1:664 SCRANTON RD
Practice Address - Street 2:SUITE 222
Practice Address - City:BRUNSWICK
Practice Address - State:GA
Practice Address - Zip Code:31520-1945
Practice Address - Country:US
Practice Address - Phone:912-264-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-04
Last Update Date:2010-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GACHIR008476111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor