Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NS0005X | Chiropractic Sports Physician | 3095 | SC |
NPI | 1134141161 |
---|---|
Provider Name | Dr. Brian E Quattlebaum |
First Address | Summerville, SC 29485-8102 |
Second Address | Summerville, SC 29485-8102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 25/07/2006 |
Last Update Date | 09/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
CH3095 | (05) | SC |
V08083 | (02) | SC |