Healthcare Provider Details

I. General information

NPI: 1093117236
Provider Name (Legal Business Name): HUDSON CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2014
Last Update Date: 09/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

46 RAVENNA ST SUITE A - 4
HUDSON OH
44236-3033
US

IV. Provider business mailing address

46 RAVENNA ST SUITE A - 4
HUDSON OH
44236-3033
US

V. Phone/Fax

Practice location:
  • Phone: 330-650-0322
  • Fax: 330-650-0327
Mailing address:
  • Phone: 330-650-0322
  • Fax: 330-650-0327

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4367
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number4367
License Number StateOH

VIII. Authorized Official

Name: DR. ROBERT S GRAVES
Title or Position: OWNER
Credential: D.C.,C.C.S.P.
Phone: 330-650-0322