Healthcare Provider Details

I. General information

NPI: 1891845046
Provider Name (Legal Business Name): TROY D. ELDRIDGE SR. D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 09/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18 W. 1ST AVENUE
ODESSA WA
99159
US

IV. Provider business mailing address

PO BOX 560
ODESSA WA
99159-0560
US

V. Phone/Fax

Practice location:
  • Phone: 509-982-2880
  • Fax:
Mailing address:
  • Phone: 509-982-2880
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number025202 CH00003217
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: