Provider Demographics
NPI:1063575389
Name:VADEN, CHARLES DOUGLAS JR (DC)
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:DOUGLAS
Last Name:VADEN
Suffix:JR
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:PO BOX 961
Mailing Address - Street 2:
Mailing Address - City:JOSHUA
Mailing Address - State:TX
Mailing Address - Zip Code:76058-0961
Mailing Address - Country:US
Mailing Address - Phone:817-705-6611
Mailing Address - Fax:
Practice Address - Street 1:214 NE WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-4117
Practice Address - Country:US
Practice Address - Phone:817-705-6611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDC6795111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX605346OtherBCBS
TX605346OtherBCBS