Healthcare Provider Details

I. General information

NPI: 1801960539
Provider Name (Legal Business Name): BRENT DEWITT D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2309 W WHITE OAKS DR
SPRINGFIELD IL
62704-7421
US

IV. Provider business mailing address

2309 W WHITE OAKS DR
SPRINGFIELD IL
62704-7421
US

V. Phone/Fax

Practice location:
  • Phone: 217-787-8188
  • Fax: 217-787-8190
Mailing address:
  • Phone: 217-787-8188
  • Fax: 217-787-8190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: