Provider Demographics
NPI:1073793345
Name:BRETON CHIROPRACTIC, INC.
Entity Type:Organization
Organization Name:BRETON CHIROPRACTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAWN
Authorized Official - Middle Name:M
Authorized Official - Last Name:BRETON
Authorized Official - Suffix:
Authorized Official - Credentials:DC, DABCI
Authorized Official - Phone:847-368-1234
Mailing Address - Street 1:106 S EMERSON ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT PROSPECT
Mailing Address - State:IL
Mailing Address - Zip Code:60056-3220
Mailing Address - Country:US
Mailing Address - Phone:847-368-1234
Mailing Address - Fax:847-603-7478
Practice Address - Street 1:815 E RAND RD
Practice Address - Street 2:
Practice Address - City:ARLINGTON HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60004-4007
Practice Address - Country:US
Practice Address - Phone:847-368-1234
Practice Address - Fax:847-603-7478
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2022-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038008779111NI0900X
IL038.009584111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NI0900XChiropractic ProvidersChiropractorInternistGroup - Multi-Specialty
No111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0001635079OtherBLUE CROSS BLUE SHIELD
IL211798OtherMEDICARE GROUP NUMBER
ILU83917Medicare UPIN