Healthcare Provider Details

I. General information

NPI: 1457309700
Provider Name (Legal Business Name): CHARLES R. CLEGG D. C.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 LOUDOUN ST SE
LEESBURG VA
20175-3115
US

IV. Provider business mailing address

PO BOX 144
LINCOLN VA
20160-0144
US

V. Phone/Fax

Practice location:
  • Phone: 703-777-8884
  • Fax:
Mailing address:
  • Phone: 540-338-2994
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number0104000216
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: