Provider Demographics
NPI:1205889961
Name:MENNETTI, BRIAN T (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:T
Last Name:MENNETTI
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:PO BOX 3108
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29484-3108
Mailing Address - Country:US
Mailing Address - Phone:843-871-7003
Mailing Address - Fax:843-871-0882
Practice Address - Street 1:137 EAST 2ND NORTH ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6628
Practice Address - Country:US
Practice Address - Phone:843-871-7003
Practice Address - Fax:843-871-0882
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2007-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1793111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC571013904OtherTAX IDENTIFICATION NUMBER
SCCH 1793Medicaid
SCGCH 123Medicaid
SCCH 1793Medicaid