Provider Demographics
NPI:1669616355
Name:DETWEILER, MICHAEL T (DC)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:T
Last Name:DETWEILER
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 1:1940 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:IL
Mailing Address - Zip Code:61530-1666
Mailing Address - Country:US
Mailing Address - Phone:309-467-2210
Mailing Address - Fax:
Practice Address - Street 1:1940 S MAIN ST
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:IL
Practice Address - Zip Code:61530-1666
Practice Address - Country:US
Practice Address - Phone:309-467-2210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-24
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.007176111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor