Provider Demographics
NPI:1710930151
Name:CRATER CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:CRATER CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-734-7333
Mailing Address - Street 1:3560 NATIONAL RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-4008
Mailing Address - Country:US
Mailing Address - Phone:541-734-7333
Mailing Address - Fax:541-734-8802
Practice Address - Street 1:3560 NATIONAL RD
Practice Address - Street 2:SUITE 100
Practice Address - City:MEDFORD
Practice Address - State:OR
Practice Address - Zip Code:97504-4008
Practice Address - Country:US
Practice Address - Phone:541-734-7333
Practice Address - Fax:541-734-8802
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-18
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272888111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1790811511OtherNPI INDIVIDUAL
OR1710930151OtherNPI GROUP
OR1790811511OtherNPI INDIVIDUAL
U51124Medicare UPIN
OR1710930151OtherNPI GROUP