Healthcare Provider Details

I. General information

NPI: 1093896631
Provider Name (Legal Business Name): CHARLES RICHARD HATHAWAY D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 11/09/2023
Certification Date: 11/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10011 SE DIVISION ST SUITE 205
PORTLAND OR
97266-1351
US

IV. Provider business mailing address

10011 SE DIVISION ST SUITE 209
PORTLAND OR
97266-1351
US

V. Phone/Fax

Practice location:
  • Phone: 503-256-2654
  • Fax: 503-256-2493
Mailing address:
  • Phone: 503-256-2654
  • Fax: 503-256-2493

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number27-1248
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: