| Organization Name: | CUSTOM CHIROPRACTIC & WELLNESS CLINIC LLC |
| NPI Number: | 1134565302 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JOSHUA DAVID FINE (OWNER/OPERATOR) |
| Mailing Address: | 1910 E Barnett Rd Ste #103 Medford |
| State: | OR US |
| Postal Code: | 975048672 |
| Phone Number: | 5412459544 |
| Fax Number: | 5412459574 |
| NPI Enumeration Date: | 05/15/2013 |
| NPI Last Update Date: | 05/15/2013 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 111N00000X |
| License Number: | 4067 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | OR |
| Taxonomy Type: | Chiropractic Providers |
| Taxonomy Classification: | Chiropractor |
| Taxonomy Specialization: | |
| Taxonomy Definition: | A provider qualified by a Doctor of Chiropractic (D.C.), licensed by the State and who practices chiropractic medicine -that discipline within the healing arts which deals with the nervous system and its relationship to the spinal column and its interrelationship with other body systems. |