Provider Demographics
NPI:1760560684
Name:DR C E BICKERTON DCCC
Entity Type:Organization
Organization Name:DR C E BICKERTON DCCC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CLIFFORD
Authorized Official - Middle Name:E
Authorized Official - Last Name:BICKERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:304-265-4200
Mailing Address - Street 1:333 LINCOLN ST
Mailing Address - Street 2:
Mailing Address - City:GRAFTON
Mailing Address - State:WV
Mailing Address - Zip Code:26354-1562
Mailing Address - Country:US
Mailing Address - Phone:304-265-4200
Mailing Address - Fax:304-265-4201
Practice Address - Street 1:333 LINCOLN ST
Practice Address - Street 2:
Practice Address - City:GRAFTON
Practice Address - State:WV
Practice Address - Zip Code:26354-1562
Practice Address - Country:US
Practice Address - Phone:304-265-4200
Practice Address - Fax:304-265-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV241111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV1316941651OtherNPI
WV001719992OtherBCBS
WV0131359000Medicaid
WV1022682OtherBRICKSTREET VENDOR NO.
WV1316941651OtherNPI
WV0131359000Medicaid
WV350017838Medicare ID - Type Unspecified