Provider Demographics
NPI:1932283843
Name:TARR, BRETT D (DC)
Entity Type:Individual
Prefix:DR
First Name:BRETT
Middle Name:D
Last Name:TARR
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 1:1301 W JOURDAN ST
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:IL
Mailing Address - Zip Code:62448-2000
Mailing Address - Country:US
Mailing Address - Phone:618-783-5900
Mailing Address - Fax:618-783-3113
Practice Address - Street 1:1301 W JOURDAN ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:IL
Practice Address - Zip Code:62448-2000
Practice Address - Country:US
Practice Address - Phone:618-783-5900
Practice Address - Fax:618-783-3113
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL037-1368797OtherTAX ID NUMBER
IL4022138OtherBLUE CROSS/BLUE SHIELD
IL4022138OtherBLUE CROSS/BLUE SHIELD
IL464521Medicare UPIN