1831387380 NPI number — INTEGRATIVE CHIROPRACTIC & WELLNESS SPA, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1831387380 NPI number — INTEGRATIVE CHIROPRACTIC & WELLNESS SPA, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INTEGRATIVE CHIROPRACTIC & WELLNESS SPA, LLC
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:
1831387380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/10/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9955 SE WASHINGTON ST
Provider Second Line Business Mailing Address:
STE 320 # 6
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97216-2439
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-253-8818
Provider Business Mailing Address Fax Number:
503-253-0377

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9955 SE WASHINGTON ST
Provider Second Line Business Practice Location Address:
STE 320 #6
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97216-2439
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-253-8818
Provider Business Practice Location Address Fax Number:
503-253-0377
Provider Enumeration Date:
10/10/2007

Additional Information

Authorized Official

Authorized Official Last Name:
MYERS
Authorized Official First Name:
CYNDI
Authorized Official Middle Name:
ROZELLA
Authorized Official Title or Position:
CHIROPRACTIC PHYSICIAN
Authorized Official Telephone Number:
360-970-1416

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3748 , 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)





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