Healthcare Provider Details

I. General information

NPI: 1033226634
Provider Name (Legal Business Name): FAMILY DYNAMICS, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 NORTH 4TH ST.
LEOTI KS
67861
US

IV. Provider business mailing address

115 NORTH 4TH STREET
LEOTI KS
67861
US

V. Phone/Fax

Practice location:
  • Phone: 620-375-5222
  • Fax: 620-375-5223
Mailing address:
  • Phone: 620-375-5222
  • Fax: 620-375-5223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number01-04805
License Number StateKS

VIII. Authorized Official

Name: DR. BRENT PORTER
Title or Position: OWNER
Credential: D.C.
Phone: 620-375-5222