Provider Demographics
NPI:1558328088
Name:DAUGHERTY, CHRIS W (DC)
Entity Type:Individual
Prefix:DR
First Name:CHRIS
Middle Name:W
Last Name:DAUGHERTY
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 1:648 N ALAMEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:LAS CRUCES
Mailing Address - State:NM
Mailing Address - Zip Code:88005-2131
Mailing Address - Country:US
Mailing Address - Phone:575-521-0022
Mailing Address - Fax:
Practice Address - Street 1:648 N ALAMEDA BLVD
Practice Address - Street 2:
Practice Address - City:LAS CRUCES
Practice Address - State:NM
Practice Address - Zip Code:88005-2131
Practice Address - Country:US
Practice Address - Phone:575-521-0022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2012-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1654111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMNM00KM71OtherBLUE CROSS
NM348625402Medicare PIN