Healthcare Provider Details

I. General information

NPI: 1831475532
Provider Name (Legal Business Name): STOUT CHIROPRACTIC CLINIC, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2011
Last Update Date: 02/26/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

214 S LINDEN ST
NORMAL IL
61761-3077
US

IV. Provider business mailing address

214 S LINDEN ST
NORMAL IL
61761-3077
US

V. Phone/Fax

Practice location:
  • Phone: 309-454-8622
  • Fax: 309-454-8626
Mailing address:
  • Phone: 309-454-8622
  • Fax: 309-454-8626

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number038-005470
License Number StateIL

VIII. Authorized Official

Name: JEFFREY KENT STOUT
Title or Position: PRESIDENT
Credential: D.C.
Phone: 309-454-8622