Provider Demographics
NPI:1265426308
Name:EDGERTON, BRENT LEE (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:LEE
Last Name:EDGERTON
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 1:7616 BROCKWAY RD
Mailing Address - Street 2:
Mailing Address - City:BROCKWAY
Mailing Address - State:MI
Mailing Address - Zip Code:48097-3408
Mailing Address - Country:US
Mailing Address - Phone:810-387-3342
Mailing Address - Fax:810-387-3543
Practice Address - Street 1:7616 BROCKWAY RD
Practice Address - Street 2:
Practice Address - City:BROCKWAY
Practice Address - State:MI
Practice Address - Zip Code:48097-3408
Practice Address - Country:US
Practice Address - Phone:810-387-3342
Practice Address - Fax:810-387-3543
Is Sole Proprietor?:No
Enumeration Date:2005-09-06
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBE006504111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI950G411160OtherBCBSMI
MI0P35900Medicare UPIN