Provider Demographics
NPI:1043429178
Name:THAXTON, STEPHEN R (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:R
Last Name:THAXTON
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 1:7717 SISSONVILLE DR
Mailing Address - Street 2:
Mailing Address - City:SISSONVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25320-9522
Mailing Address - Country:US
Mailing Address - Phone:304-988-1922
Mailing Address - Fax:304-988-0130
Practice Address - Street 1:7717 SISSONVILLE DR
Practice Address - Street 2:
Practice Address - City:SISSONVILLE
Practice Address - State:WV
Practice Address - Zip Code:25320-9522
Practice Address - Country:US
Practice Address - Phone:304-988-1922
Practice Address - Fax:304-988-0130
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-22
Last Update Date:2021-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV554111NR0200X, 111NR0400X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NR0400XChiropractic ProvidersChiropractorRehabilitation
No111NR0200XChiropractic ProvidersChiropractorRadiology
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV0010707548OtherMOUNTAIN STATE
WV013224900Medicaid
WV4229471Medicare PIN
WVU84657Medicare UPIN