Healthcare Provider Details

I. General information

NPI: 1710930151
Provider Name (Legal Business Name): CRATER CHIROPRACTIC CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 10/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3560 NATIONAL RD SUITE 100
MEDFORD OR
97504-4008
US

IV. Provider business mailing address

3560 NATIONAL RD SUITE 100
MEDFORD OR
97504-4008
US

V. Phone/Fax

Practice location:
  • Phone: 541-734-7333
  • Fax: 541-734-8802
Mailing address:
  • Phone: 541-734-7333
  • Fax: 541-734-8802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number272888
License Number StateOR

VIII. Authorized Official

Name: MICHAEL L WARREN
Title or Position: PRESIDENT
Credential: DC
Phone: 541-734-7333