Provider Demographics
NPI:1265914337
Name:WITTHOFT, DYLAN C (DC)
Entity type:Individual
Prefix:DR
First Name:DYLAN
Middle Name:C
Last Name:WITTHOFT
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 1:1332 W ARCH HAVEN AVE STE C
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47403-2078
Mailing Address - Country:US
Mailing Address - Phone:812-333-7447
Mailing Address - Fax:812-333-7442
Practice Address - Street 1:1332 W ARCH HAVEN AVE STE C
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47403-2078
Practice Address - Country:US
Practice Address - Phone:812-333-7447
Practice Address - Fax:812-333-7442
Is Sole Proprietor?:No
Enumeration Date:2018-09-05
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN08003052A111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor