Provider Demographics
NPI:1225264245
Name:MCGILLEM, DEVON TYLER (DC)
Entity Type:Individual
Prefix:DR
First Name:DEVON
Middle Name:TYLER
Last Name:MCGILLEM
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 1:450 S STATE ROAD 135
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46142-1455
Mailing Address - Country:US
Mailing Address - Phone:317-889-8998
Mailing Address - Fax:317-889-9127
Practice Address - Street 1:450 S STATE ROAD 135
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:IN
Practice Address - Zip Code:46142-1455
Practice Address - Country:US
Practice Address - Phone:317-889-8998
Practice Address - Fax:317-889-9127
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-04
Last Update Date:2014-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08002450A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor