Provider Demographics
NPI:1154475606
Name:WETTACH, CHARLES (DC)
Entity Type:Individual
Prefix:MR
First Name:CHARLES
Middle Name:
Last Name:WETTACH
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 1:22 2ND AVE W
Mailing Address - Street 2:SUITE 1000
Mailing Address - City:KALISPELL
Mailing Address - State:MT
Mailing Address - Zip Code:59901
Mailing Address - Country:US
Mailing Address - Phone:406-257-0550
Mailing Address - Fax:406-257-0550
Practice Address - Street 1:22 2ND AVE W
Practice Address - Street 2:SUITE 1000
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901
Practice Address - Country:US
Practice Address - Phone:406-257-0550
Practice Address - Fax:406-257-0550
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTC 367111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor