Provider Demographics
NPI:1285921833
Name:WISE, BRENT L (DC)
Entity type:Individual
Prefix:DR
First Name:BRENT
Middle Name:L
Last Name:WISE
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2723 FYNAMORE LN
Mailing Address - Street 2:
Mailing Address - City:DOWNINGTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:19335-6028
Mailing Address - Country:US
Mailing Address - Phone:484-593-0328
Mailing Address - Fax:484-593-0440
Practice Address - Street 1:533 W UWCHLAN AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:DOWNINGTOWN
Practice Address - State:PA
Practice Address - Zip Code:19335-1763
Practice Address - Country:US
Practice Address - Phone:484-593-0328
Practice Address - Fax:484-593-0440
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2012-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACH10298111N00000X
PADC010614111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor