Provider Demographics
NPI:1093896631
Name:HATHAWAY, CHARLES RICHARD (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:RICHARD
Last Name:HATHAWAY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10011 SE DIVISION ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97266-1351
Mailing Address - Country:US
Mailing Address - Phone:503-256-2654
Mailing Address - Fax:503-256-2493
Practice Address - Street 1:10011 SE DIVISION ST
Practice Address - Street 2:SUITE 205
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97266-1351
Practice Address - Country:US
Practice Address - Phone:503-256-2654
Practice Address - Fax:503-256-2493
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-18
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-1248111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR20-1718201OtherTAX ID