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General NPI Number Information
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NPI Number | 1134565302
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Entity Type | Organization
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Legal Business Name | CUSTOM CHIROPRACTIC & WELLNESS CLINIC LLC
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Dates
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Enumeration Date | 05/15/2013
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Last Update Date | 05/15/2013
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Provider Practice Location Address
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Address Line | 1910 E BARNETT RD STE #103
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City | MEDFORD
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State | OR
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Zip | 97504-8672
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Country | US
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Telephone | 541-245-9544
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Fax | 541-245-9574
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Provider Business Mailing Address
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Address Line | 1910 E BARNETT RD STE #103
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City | MEDFORD
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State | OR
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Zip | 97504-8672
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Country | US
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Telephone | 541-245-9544
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Fax | 541-245-9574
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Authorized Official
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Title or Position | OWNER/OPERATOR
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Name | DR. JOSHUA DAVID FINE
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Credential | D.C.
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Telephone | 541-245-9544
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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 | 4067
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License Number State | OR
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