Provider Demographics
NPI:1427142066
Name:EDMISTON, BRYAN SCOTT (DC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:SCOTT
Last Name:EDMISTON
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 1:523 FENTON PL
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1919
Mailing Address - Country:US
Mailing Address - Phone:704-302-1524
Mailing Address - Fax:
Practice Address - Street 1:523 FENTON PL
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1919
Practice Address - Country:US
Practice Address - Phone:704-302-1524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3182111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCU96247Medicare UPIN