Provider Demographics
NPI:1831475532
Name:STOUT CHIROPRACTIC CLINIC, PC
Entity Type:Organization
Organization Name:STOUT CHIROPRACTIC CLINIC, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:KENT
Authorized Official - Last Name:STOUT
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:309-454-8622
Mailing Address - Street 1:214 S LINDEN ST
Mailing Address - Street 2:
Mailing Address - City:NORMAL
Mailing Address - State:IL
Mailing Address - Zip Code:61761-3077
Mailing Address - Country:US
Mailing Address - Phone:309-454-8622
Mailing Address - Fax:309-454-8626
Practice Address - Street 1:214 S LINDEN ST
Practice Address - Street 2:
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-3077
Practice Address - Country:US
Practice Address - Phone:309-454-8622
Practice Address - Fax:309-454-8626
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-10-25
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-005470261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty