1669802617 NPI number — CLOCK TOWER CHIROPRACTIC & MASSAGE PC

Table of content: (NPI 1669802617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669802617 NPI number — CLOCK TOWER CHIROPRACTIC & MASSAGE PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOCK TOWER CHIROPRACTIC & MASSAGE PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1669802617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 966
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILSONVILLE
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97070-0966
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-685-9841
Provider Business Mailing Address Fax Number:
503-682-9069

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8642 SW MAIN ST
Provider Second Line Business Practice Location Address:
SUITE #130
Provider Business Practice Location Address City Name:
WILSONVILLE
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97070-6585
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-685-9841
Provider Business Practice Location Address Fax Number:
503-682-9069
Provider Enumeration Date:
11/12/2013

Additional Information

Authorized Official

Authorized Official Last Name:
COLBY
Authorized Official First Name:
SARAH
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PRINCICPLE OPERATOR
Authorized Official Telephone Number:
503-685-9841

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  23365 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: R134000 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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