=====================================================
General NPI Number Information
=====================================================
NPI Number | 1003361783
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WESTON ALLEN HOLZINGER D.C.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/23/2016
-----------------------------------------------------
Last Update Date | 08/23/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 922 TALON DR SUITE B
-----------------------------------------------------
City | O FALLON
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62269-1848
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-622-1200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3402 STATE ROUTE 160
-----------------------------------------------------
City | HIGHLAND
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 62249-1034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 618-791-6536
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 038.013007
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------