Provider Demographics
NPI:1134778418
Name:DEIG, BENJAMIN CHARLES (DC)
Entity type:Individual
Prefix:
First Name:BENJAMIN
Middle Name:CHARLES
Last Name:DEIG
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 1:316 E EDGEWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MORTON
Mailing Address - State:IL
Mailing Address - Zip Code:61550-2534
Mailing Address - Country:US
Mailing Address - Phone:309-369-5474
Mailing Address - Fax:
Practice Address - Street 1:7800 N SOMMER ST STE 203
Practice Address - Street 2:
Practice Address - City:PEORIA
Practice Address - State:IL
Practice Address - Zip Code:61615-1990
Practice Address - Country:US
Practice Address - Phone:309-691-9767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-09
Last Update Date:2019-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL390200000X
IL038.013464111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program