Provider Demographics
NPI:1063769214
Name:CHARLES E HOLTON, JR DC INC
Entity type:Organization
Organization Name:CHARLES E HOLTON, JR DC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:E
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-623-3903
Mailing Address - Street 1:289 E ELLENDALE AVE
Mailing Address - Street 2:STE 102
Mailing Address - City:DALLAS
Mailing Address - State:OR
Mailing Address - Zip Code:97338-1580
Mailing Address - Country:US
Mailing Address - Phone:503-623-3903
Mailing Address - Fax:503-623-3803
Practice Address - Street 1:289 E ELLENDALE AVE
Practice Address - Street 2:STE 102
Practice Address - City:DALLAS
Practice Address - State:OR
Practice Address - Zip Code:97338-1580
Practice Address - Country:US
Practice Address - Phone:503-623-3903
Practice Address - Fax:503-623-3803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-07
Last Update Date:2015-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67733Medicare UPIN