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General NPI Number Information
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NPI Number | 1134159924
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Entity Type | Organization
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Legal Business Name | CHILDRESS CHIROPRACTIC, SPINAL REHAB & WELLNESS
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Dates
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Enumeration Date | 07/04/2006
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Last Update Date | 04/17/2008
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Provider Practice Location Address
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Address Line | 619 W MAIN ST STE B
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City | LEBANON
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State | VA
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Zip | 24266-3809
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Country | US
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Telephone | 276-889-1314
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Fax | 276-889-4125
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Provider Business Mailing Address
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Address Line | PO BOX 1300 619 W MAIN ST STE B
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City | LEBANON
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State | VA
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Zip | 24266-1300
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Country | US
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Telephone | 276-889-1314
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Fax | 276-889-4125
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Authorized Official
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Title or Position | OWNER
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Name | DR. STEPHEN LEWIS CHILDRESS
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Credential | D.C.
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Telephone | 276-889-1314
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 0104-001354
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License Number State | VA
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