Provider Demographics
NPI:1801966429
Name:DEWIRE, BRIAN CHARLES (DC)
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHARLES
Last Name:DEWIRE
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:P.O. BOX 708
Mailing Address - Street 2:
Mailing Address - City:PAINTSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:41240
Mailing Address - Country:US
Mailing Address - Phone:606-788-0015
Mailing Address - Fax:
Practice Address - Street 1:705 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:PAINTSVILLE
Practice Address - State:KY
Practice Address - Zip Code:41240-1513
Practice Address - Country:US
Practice Address - Phone:606-788-0015
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-09
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4591111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY85000552Medicaid
KYU81891Medicare UPIN
KY85000552Medicaid