Provider Demographics
NPI:1285684332
Name:CHILDRESS, STEPHEN LEWIS I (DC)
Entity Type:Individual
Prefix:
First Name:STEPHEN
Middle Name:LEWIS
Last Name:CHILDRESS
Suffix:I
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:PO BOX 1300
Mailing Address - Street 2:307 W MAIN STREET
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266
Mailing Address - Country:US
Mailing Address - Phone:276-889-2200
Mailing Address - Fax:276-889-2202
Practice Address - Street 1:619 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3809
Practice Address - Country:US
Practice Address - Phone:276-889-1314
Practice Address - Fax:276-889-4125
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-11
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104001354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA236332OtherANTHEM
VA0300608Medicaid
VA5010623OtherAETNA
VA236332OtherANTHEM
VA0300608Medicaid
VA00V199C03Medicare PIN
VADB9951Medicare UPIN
VAP00141477Medicare PIN