Provider Demographics
NPI:1710197405
Name:CLOGSTON, RAY THOMAS (DC)
Entity Type:Individual
Prefix:
First Name:RAY
Middle Name:THOMAS
Last Name:CLOGSTON
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 1:337 WEST MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:WA
Mailing Address - Zip Code:98272-1811
Mailing Address - Country:US
Mailing Address - Phone:360-794-4131
Mailing Address - Fax:360-794-4131
Practice Address - Street 1:337 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:WA
Practice Address - Zip Code:98272-1811
Practice Address - Country:US
Practice Address - Phone:360-794-4131
Practice Address - Fax:360-794-4131
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH00002922111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
ABO1976Medicare UPIN