Provider Demographics
NPI:1154438802
Name:TIDWELL, BRENT ALAN (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:ALAN
Last Name:TIDWELL
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 MIMOSA PARK ROAD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-3964
Mailing Address - Country:US
Mailing Address - Phone:205-752-7503
Mailing Address - Fax:205-752-7513
Practice Address - Street 1:819 MIMOSA PARK RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-4839
Practice Address - Country:US
Practice Address - Phone:205-752-7503
Practice Address - Fax:205-752-7513
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2015-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1802111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51035545OtherBLUE CROSS
AL51542858OtherBLUE CROSS
AL000035545Medicare ID - Type Unspecified
AL51542858OtherBLUE CROSS