Provider Demographics
NPI:1780703413
Name:WHITLEY, BRENT (DC)
Entity type:Individual
Prefix:
First Name:BRENT
Middle Name:
Last Name:WHITLEY
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 1:316 HIGHWAY 6 AND 50 STE B
Mailing Address - Street 2:
Mailing Address - City:FRUITA
Mailing Address - State:CO
Mailing Address - Zip Code:81521-2642
Mailing Address - Country:US
Mailing Address - Phone:970-858-0544
Mailing Address - Fax:970-858-7749
Practice Address - Street 1:1500 ALPINE AVE
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-3508
Practice Address - Country:US
Practice Address - Phone:303-449-7226
Practice Address - Fax:303-449-5009
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6002111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor