Healthcare Provider Details

I. General information

NPI: 1114045861
Provider Name (Legal Business Name): BRENT EVERETT WATSON D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

316 N MAIN ST
BROOKFIELD MO
64628-1601
US

IV. Provider business mailing address

113 MAPLE ST
BUCKLIN MO
64631-9113
US

V. Phone/Fax

Practice location:
  • Phone: 660-258-4646
  • Fax:
Mailing address:
  • Phone: 660-695-3635
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2006032871
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: