Provider Demographics
NPI:1902214992
Name:ANDERSON, CHAD
Entity Type:Individual
Prefix:
First Name:CHAD
Middle Name:
Last Name:ANDERSON
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:PO BOX 7967
Mailing Address - Street 2:
Mailing Address - City:BROOKINGS
Mailing Address - State:OR
Mailing Address - Zip Code:97415-0374
Mailing Address - Country:US
Mailing Address - Phone:541-469-2276
Mailing Address - Fax:541-469-0489
Practice Address - Street 1:411 MILL BEACH RD
Practice Address - Street 2:STE A
Practice Address - City:BROOKINGS
Practice Address - State:OR
Practice Address - Zip Code:97415-9690
Practice Address - Country:US
Practice Address - Phone:541-469-2276
Practice Address - Fax:541-469-0489
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-23
Last Update Date:2016-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5716111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor