Provider Demographics
NPI:1386823664
Name:BRENT C PAXTON P C
Entity Type:Organization
Organization Name:BRENT C PAXTON P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:C
Authorized Official - Last Name:PAXTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:847-746-3777
Mailing Address - Street 1:2248 SHERIDAN RD
Mailing Address - Street 2:SUITE 2
Mailing Address - City:ZION
Mailing Address - State:IL
Mailing Address - Zip Code:60099-2329
Mailing Address - Country:US
Mailing Address - Phone:847-746-3777
Mailing Address - Fax:
Practice Address - Street 1:2248 SHERIDAN RD
Practice Address - Street 2:SUITE 2
Practice Address - City:ZION
Practice Address - State:IL
Practice Address - Zip Code:60099-2329
Practice Address - Country:US
Practice Address - Phone:847-746-3777
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-02
Last Update Date:2007-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL04982069OtherBC BS
780 650Medicare PIN