Provider Demographics
NPI:1962448183
Name:GANTT, STACY K (DC)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:K
Last Name:GANTT
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 S DEAN ST
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29302-1986
Mailing Address - Country:US
Mailing Address - Phone:864-583-3967
Mailing Address - Fax:864-585-5554
Practice Address - Street 1:201 S DEAN ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29302-1986
Practice Address - Country:US
Practice Address - Phone:864-583-3967
Practice Address - Fax:864-585-5554
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2391111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2391Medicaid
SCCH2391Medicaid
SCU818550281Medicare ID - Type Unspecified