Provider Demographics
NPI:1134159924
Name:CHILDRESS CHIROPRACTIC, SPINAL REHAB & WELLNESS
Entity type:Organization
Organization Name:CHILDRESS CHIROPRACTIC, SPINAL REHAB & WELLNESS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:LEWIS
Authorized Official - Last Name:CHILDRESS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:276-889-1314
Mailing Address - Street 1:PO BOX 1300
Mailing Address - Street 2:619 W MAIN ST STE B
Mailing Address - City:LEBANON
Mailing Address - State:VA
Mailing Address - Zip Code:24266-1300
Mailing Address - Country:US
Mailing Address - Phone:276-889-1314
Mailing Address - Fax:276-889-4125
Practice Address - Street 1:619 W MAIN ST STE B
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:VA
Practice Address - Zip Code:24266-3809
Practice Address - Country:US
Practice Address - Phone:276-889-1314
Practice Address - Fax:276-889-4125
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0104-001354111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA000300608Medicaid
VA236332OtherANTHEM
VA5010623OtherAETNA
VA236332OtherANTHEM
P00141477Medicare PIN
VAU60435Medicare UPIN