Healthcare Provider Details

I. General information

NPI: 1265426308
Provider Name (Legal Business Name): BRENT LEE EDGERTON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2005
Last Update Date: 06/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7616 BROCKWAY RD
BROCKWAY MI
48097-3408
US

IV. Provider business mailing address

7616 BROCKWAY RD
BROCKWAY MI
48097-3408
US

V. Phone/Fax

Practice location:
  • Phone: 810-387-3342
  • Fax: 810-387-3543
Mailing address:
  • Phone: 810-387-3342
  • Fax: 810-387-3543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberBE006504
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: