Healthcare Provider Details

I. General information

NPI: 1427006014
Provider Name (Legal Business Name): CHARLES MARTIN ANDERSON D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W STEWART AVE STE101
MEDFORD OR
97501-3600
US

IV. Provider business mailing address

255 W STEWART AVE STE101
MEDFORD OR
97501-3600
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-9650
  • Fax: 541-779-5315
Mailing address:
  • Phone: 541-779-9650
  • Fax: 541-779-5315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number2453
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: