Provider Demographics
NPI:1780781757
Name:POLING, BRETT TYSON (DC)
Entity type:Individual
Prefix:
First Name:BRETT
Middle Name:TYSON
Last Name:POLING
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 166
Mailing Address - Street 2:
Mailing Address - City:SAINT FRANCIS
Mailing Address - State:KS
Mailing Address - Zip Code:67756-0166
Mailing Address - Country:US
Mailing Address - Phone:785-332-3105
Mailing Address - Fax:785-332-3188
Practice Address - Street 1:709 S BENTON ST
Practice Address - Street 2:
Practice Address - City:SAINT FRANCIS
Practice Address - State:KS
Practice Address - Zip Code:67756-3508
Practice Address - Country:US
Practice Address - Phone:785-332-3105
Practice Address - Fax:785-332-3188
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS01-04771111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS060896Medicare ID - Type Unspecified
KSU89761Medicare UPIN