Provider Demographics
NPI:1679668693
Name:CUSTER, TERRY REED (DC)
Entity type:Individual
Prefix:DR
First Name:TERRY
Middle Name:REED
Last Name:CUSTER
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 1:1390 N FAIRVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62526-3618
Mailing Address - Country:US
Mailing Address - Phone:217-423-4070
Mailing Address - Fax:217-423-8325
Practice Address - Street 1:1390 N FAIRVIEW AVE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62526-3618
Practice Address - Country:US
Practice Address - Phone:217-423-4070
Practice Address - Fax:217-423-8325
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL613820Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER