Provider Demographics
NPI:1710442173
Name:ETHEREDGE, CHRISTOPHER AJ
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:AJ
Last Name:ETHEREDGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7525 JUDGE LOGUE RD
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:AL
Mailing Address - Zip Code:36352-8909
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7525 JUDGE LOGUE RD
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:AL
Practice Address - Zip Code:36352-8909
Practice Address - Country:US
Practice Address - Phone:334-714-5180
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-09
Last Update Date:2019-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer