Provider Demographics
NPI:1386964385
Name:GILLENWATER, BRANDON HETH (DC)
Entity type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:HETH
Last Name:GILLENWATER
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 1:2110 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:VA
Mailing Address - Zip Code:24201-3612
Mailing Address - Country:US
Mailing Address - Phone:276-669-9158
Mailing Address - Fax:276-669-6261
Practice Address - Street 1:2110 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:VA
Practice Address - Zip Code:24201-3612
Practice Address - Country:US
Practice Address - Phone:276-669-9158
Practice Address - Fax:276-669-6261
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-02
Last Update Date:2021-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104556807111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor