Healthcare Provider Details

I. General information

NPI: 1588657357
Provider Name (Legal Business Name): BRENT PORTER D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 N. 4TH ST.
LEOTI KS
67861
US

IV. Provider business mailing address

115 NORTH 4TH ST.
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 Number4805
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: