Provider Demographics
NPI:1033291034
Name:WATKINS, BRETT ALLEN (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:ALLEN
Last Name:WATKINS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 87
Mailing Address - Street 2:301 JACKSON
Mailing Address - City:MCLEANSBORO
Mailing Address - State:IL
Mailing Address - Zip Code:62859
Mailing Address - Country:US
Mailing Address - Phone:618-643-3833
Mailing Address - Fax:618-643-2494
Practice Address - Street 1:301 S JACKSON
Practice Address - Street 2:
Practice Address - City:MCLEANSBORO
Practice Address - State:IL
Practice Address - Zip Code:62859
Practice Address - Country:US
Practice Address - Phone:618-643-3833
Practice Address - Fax:618-643-2494
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2010-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008693111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL038008693Medicaid
IL03923143OtherBCBS
IL553350Medicare ID - Type Unspecified
IL038008693Medicaid