1134565302 NPI number — CUSTOM CHIROPRACTIC & WELLNESS CLINIC LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134565302 NPI number — CUSTOM CHIROPRACTIC & WELLNESS CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CUSTOM CHIROPRACTIC & WELLNESS CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1134565302
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/15/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1910 E BARNETT RD
Provider Second Line Business Mailing Address:
STE #103
Provider Business Mailing Address City Name:
MEDFORD
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97504-8672
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-245-9544
Provider Business Mailing Address Fax Number:
541-245-9574

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1910 E BARNETT RD
Provider Second Line Business Practice Location Address:
STE #103
Provider Business Practice Location Address City Name:
MEDFORD
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97504-8672
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-245-9544
Provider Business Practice Location Address Fax Number:
541-245-9574
Provider Enumeration Date:
05/15/2013

Additional Information

Authorized Official

Authorized Official Last Name:
FINE
Authorized Official First Name:
JOSHUA
Authorized Official Middle Name:
DAVID
Authorized Official Title or Position:
OWNER/OPERATOR
Authorized Official Telephone Number:
541-245-9544

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  4067 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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