Provider Demographics
NPI:1508454737
Name:HOLMES, PAYTON (DC)
Entity Type:Individual
Prefix:
First Name:PAYTON
Middle Name:
Last Name:HOLMES
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 1:510 NE 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:ALEDO
Mailing Address - State:IL
Mailing Address - Zip Code:61231-1155
Mailing Address - Country:US
Mailing Address - Phone:309-299-6968
Mailing Address - Fax:
Practice Address - Street 1:107 N MAIN ST
Practice Address - Street 2:
Practice Address - City:MONMOUTH
Practice Address - State:IL
Practice Address - Zip Code:61462-1738
Practice Address - Country:US
Practice Address - Phone:309-299-6968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-04
Last Update Date:2021-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.013623111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor