Provider Demographics
NPI:1427379528
Name:FENTON, STEPHEN MATTHEW (DC)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:MATTHEW
Last Name:FENTON
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 1:19244 HURRICANE DR
Mailing Address - Street 2:
Mailing Address - City:CARLINVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62626-9380
Mailing Address - Country:US
Mailing Address - Phone:217-556-4865
Mailing Address - Fax:
Practice Address - Street 1:490 W SIDE SQ
Practice Address - Street 2:
Practice Address - City:CARLINVILLE
Practice Address - State:IL
Practice Address - Zip Code:62626-1796
Practice Address - Country:US
Practice Address - Phone:217-854-2557
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-06-13
Last Update Date:2010-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038-011703111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor