Provider Demographics
NPI:1700997483
Name:HENDRICKS, CHARLES MARK (DC)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:MARK
Last Name:HENDRICKS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 NORTH MAIN
Mailing Address - Street 2:
Mailing Address - City:ASHLAND CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37015
Mailing Address - Country:US
Mailing Address - Phone:615-792-5112
Mailing Address - Fax:615-792-5165
Practice Address - Street 1:112 NORTH MAIN
Practice Address - Street 2:
Practice Address - City:ASHLAND CITY
Practice Address - State:TN
Practice Address - Zip Code:37015
Practice Address - Country:US
Practice Address - Phone:615-792-5112
Practice Address - Fax:615-792-5165
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNTN1729111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3971523Medicaid
TN3971523Medicaid
TN3971523Medicare ID - Type Unspecified