Provider Demographics
NPI:1285958868
Name:DEWITT CHIROPRACTIC, PLLC
Entity type:Organization
Organization Name:DEWITT CHIROPRACTIC, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRADFORD
Authorized Official - Middle Name:J
Authorized Official - Last Name:DEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:228-832-0846
Mailing Address - Street 1:15465 OAK LN
Mailing Address - Street 2:SUITE 100B
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-2663
Mailing Address - Country:US
Mailing Address - Phone:228-832-0846
Mailing Address - Fax:228-832-0856
Practice Address - Street 1:15465 OAK LN
Practice Address - Street 2:SUITE 100B
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503-2663
Practice Address - Country:US
Practice Address - Phone:228-832-0846
Practice Address - Fax:228-832-0856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-25
Last Update Date:2013-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1145111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS93014524OtherUNITED HEALTH CARE
MS953596Medicaid
MS302I354509OtherMEDICARE
MS9194329OtherAETNA