Provider Demographics
NPI:1013965029
Name:MEDECK, ROBERT (DC CCST)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:
Last Name:MEDECK
Suffix:
Gender:M
Credentials:DC CCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1875 HIGHWAY 99 N
Mailing Address - Street 2:STE 11
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-9120
Mailing Address - Country:US
Mailing Address - Phone:541-482-2225
Mailing Address - Fax:541-488-2962
Practice Address - Street 1:1875 HWY 99 N
Practice Address - Street 2:STE 11
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520
Practice Address - Country:US
Practice Address - Phone:541-482-2225
Practice Address - Fax:541-488-2962
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-04
Last Update Date:2015-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2147111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR230721Medicaid
ORR0000QGHKCMedicare ID - Type Unspecified