Provider Demographics
NPI:1083676753
Name:MCCLELLAN, CHARLES KENNETH JR (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:KENNETH
Last Name:MCCLELLAN
Suffix:JR
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:718 THOMPSON LN
Mailing Address - Street 2:SUITE 119
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37204-3612
Mailing Address - Country:US
Mailing Address - Phone:615-292-2797
Mailing Address - Fax:615-467-0963
Practice Address - Street 1:718 THOMPSON LN
Practice Address - Street 2:SUITE 119
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37204-3612
Practice Address - Country:US
Practice Address - Phone:615-292-2797
Practice Address - Fax:615-467-0963
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2007-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDC0000001477111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4118747OtherBCBS
TNU71624Medicare UPIN
TN3679931Medicare PIN