Provider Demographics
NPI:1427006014
Name:ANDERSON, CHARLES MARTIN (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARTIN
Last Name:ANDERSON
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 1:255 W STEWART AVE
Mailing Address - Street 2:STE101
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97501-3600
Mailing Address - Country:US
Mailing Address - Phone:541-779-9650
Mailing Address - Fax:541-779-5315
Practice Address - Street 1:255 W STEWART AVE
Practice Address - Street 2:STE101
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97501-3600
Practice Address - Country:US
Practice Address - Phone:541-779-9650
Practice Address - Fax:541-779-5315
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2008-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2453111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR085306000OtherBC/BS