Provider Demographics
NPI:1710921465
Name:PAYTON, GLENN WEBSTER (DC)
Entity Type:Individual
Prefix:DR
First Name:GLENN
Middle Name:WEBSTER
Last Name:PAYTON
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 1:425 WEST FRONT ST.
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:IL
Mailing Address - Zip Code:61738
Mailing Address - Country:US
Mailing Address - Phone:309-527-4150
Mailing Address - Fax:
Practice Address - Street 1:425 W FRONT ST
Practice Address - Street 2:
Practice Address - City:EL PASO
Practice Address - State:IL
Practice Address - Zip Code:61738-1422
Practice Address - Country:US
Practice Address - Phone:309-527-4150
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-15
Last Update Date:2024-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038006522111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL10215000OtherBLUE CROSS/BLUE SHIELD
IL203190Medicare ID - Type Unspecified