Healthcare Provider Details

I. General information

NPI: 1407956626
Provider Name (Legal Business Name): STEPHEN MARK WEISS D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 E FRONT ST
BLOOMINGTON IL
61701-5309
US

IV. Provider business mailing address

409 E FRONT ST
BLOOMINGTON IL
61701-5309
US

V. Phone/Fax

Practice location:
  • Phone: 309-828-3415
  • Fax: 309-828-2665
Mailing address:
  • Phone: 309-828-3415
  • Fax: 309-828-2665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number038-004679
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: