Provider Demographics
NPI:1457309700
Name:CLEGG, CHARLES R (D C)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:CLEGG
Suffix:
Gender:M
Credentials:D C
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 144
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:VA
Mailing Address - Zip Code:20160-0144
Mailing Address - Country:US
Mailing Address - Phone:540-338-2994
Mailing Address - Fax:
Practice Address - Street 1:225 LOUDOUN ST SE
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:VA
Practice Address - Zip Code:20175-3115
Practice Address - Country:US
Practice Address - Phone:703-777-8884
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104000216111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAT21442Medicare UPIN
VA00V112C46Medicare ID - Type Unspecified