Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NX0800X | Chiropractor Orthopedic Specialist | 0104000216 | VA |
NPI | 1457309700 |
---|---|
Provider Name | Dr. Charles R. Clegg |
First Address | Lincoln, VA 20160-0144 |
Second Address | Leesburg, VA 20175-3115 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 05/05/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
T21442 | (02) | VA |