Provider Demographics
NPI:1316929235
Name:CLASQUIN, BRETT WILLIAM (DC)
Entity type:Individual
Prefix:DR
First Name:BRETT
Middle Name:WILLIAM
Last Name:CLASQUIN
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:PO BOX 307
Mailing Address - Street 2:221 S MAIN ST
Mailing Address - City:SMITHTON
Mailing Address - State:IL
Mailing Address - Zip Code:62285-0307
Mailing Address - Country:US
Mailing Address - Phone:618-235-4120
Mailing Address - Fax:618-235-4120
Practice Address - Street 1:221 S MAIN ST
Practice Address - Street 2:
Practice Address - City:SMITHTON
Practice Address - State:IL
Practice Address - Zip Code:62285-1709
Practice Address - Country:US
Practice Address - Phone:618-235-4120
Practice Address - Fax:618-235-4120
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-16
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038 007776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
379600Medicare ID - Type Unspecified