Provider Demographics
NPI:1477653921
Name:HOLTON, CHARLES E JR (DC)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:E
Last Name:HOLTON
Suffix:JR
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 1:289 E ELLENDALE AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338
Mailing Address - Country:US
Mailing Address - Phone:503-623-3903
Mailing Address - Fax:503-623-3803
Practice Address - Street 1:289 E ELLENDALE AVE
Practice Address - Street 2:STE 102
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338
Practice Address - Country:US
Practice Address - Phone:503-623-3903
Practice Address - Fax:503-623-3803
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1963111N00000X
WA0206594111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
T67733Medicare UPIN
R0000QGFBLMedicare ID - Type Unspecified