Provider Demographics
NPI:1588782528
Name:HAGEN, TRENT CHRIS (DC)
Entity type:Individual
Prefix:
First Name:TRENT
Middle Name:CHRIS
Last Name:HAGEN
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 1:993 GALENA SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:GALENA
Mailing Address - State:IL
Mailing Address - Zip Code:61036-1355
Mailing Address - Country:US
Mailing Address - Phone:815-777-1123
Mailing Address - Fax:
Practice Address - Street 1:993 GALENA SQUARE DR
Practice Address - Street 2:
Practice Address - City:GALENA
Practice Address - State:IL
Practice Address - Zip Code:61036-1355
Practice Address - Country:US
Practice Address - Phone:815-777-1123
Practice Address - Fax:815-777-2212
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2012-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 5120111N00000X
IAA05427111N00000X
IL038-010723111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL6341Medicaid
ILIL6341Medicaid