Provider Demographics
NPI:1134262280
Name:SWANN, JUSTIN FORREST (DC)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:FORREST
Last Name:SWANN
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 1:613 13TH ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:KY
Mailing Address - Zip Code:41101-2617
Mailing Address - Country:US
Mailing Address - Phone:606-329-8080
Mailing Address - Fax:606-325-8550
Practice Address - Street 1:613 13TH ST.
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:KY
Practice Address - Zip Code:41101-2669
Practice Address - Country:US
Practice Address - Phone:606-329-8080
Practice Address - Fax:606-325-8550
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-15
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4525111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000818Medicaid
6099101Medicare ID - Type Unspecified
KY85000818Medicaid