Healthcare Provider Details

I. General information

NPI: 1043429178
Provider Name (Legal Business Name): STEPHEN R THAXTON DC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 03/25/2021
Certification Date: 03/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7717 SISSONVILLE DR
SISSONVILLE WV
25320-9522
US

IV. Provider business mailing address

7717 SISSONVILLE DR
SISSONVILLE WV
25320-9522
US

V. Phone/Fax

Practice location:
  • Phone: 304-988-1922
  • Fax: 304-988-0130
Mailing address:
  • Phone: 304-988-1922
  • Fax: 304-988-0130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number554
License Number StateWV
# 2
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number554
License Number StateWV
# 3
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number554
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: