Provider Demographics
NPI:1932313145
Name:TANNER, BRANDON MICHAEL (DC)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:MICHAEL
Last Name:TANNER
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 1:333 PRADO WAY
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607-6512
Mailing Address - Country:US
Mailing Address - Phone:864-627-4272
Mailing Address - Fax:864-640-8562
Practice Address - Street 1:333 PRADO WAY
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607-6512
Practice Address - Country:US
Practice Address - Phone:360-420-6907
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-09
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3159111N00000X
WACH34404111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAVO2487Medicare UPIN