Provider Demographics
NPI:1982661963
Name:GENTRY, ADAM BLAIR (DC)
Entity Type:Individual
Prefix:
First Name:ADAM
Middle Name:BLAIR
Last Name:GENTRY
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 1:1115 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29483-3072
Mailing Address - Country:US
Mailing Address - Phone:843-832-4499
Mailing Address - Fax:843-832-4978
Practice Address - Street 1:1115 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-3072
Practice Address - Country:US
Practice Address - Phone:843-832-4499
Practice Address - Fax:843-832-4978
Is Sole Proprietor?:No
Enumeration Date:2006-04-26
Last Update Date:2007-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2478111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCCH2478Medicaid
SCU81041Medicare UPIN