Provider Demographics
NPI:1659333557
Name:SPENCER, BRANT D (DC PC)
Entity type:Individual
Prefix:DR
First Name:BRANT
Middle Name:D
Last Name:SPENCER
Suffix:
Gender:M
Credentials:DC PC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 1548
Mailing Address - Street 2:
Mailing Address - City:BLANCHARD
Mailing Address - State:OK
Mailing Address - Zip Code:73010
Mailing Address - Country:US
Mailing Address - Phone:405-485-9646
Mailing Address - Fax:405-485-3464
Practice Address - Street 1:104 S. MAIN
Practice Address - Street 2:
Practice Address - City:BLANCHARD
Practice Address - State:OK
Practice Address - Zip Code:73010
Practice Address - Country:US
Practice Address - Phone:405-485-9646
Practice Address - Fax:405-485-3464
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-05
Last Update Date:2014-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK3306111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK243515400Medicare PIN
OK243515400Medicare ID - Type Unspecified
OK1811154008Medicare PIN