1154779791 NPI number — MILWAUKIE CHIROPRACTIC - DR. JESSE BROCKEY LLC

Table of content: (NPI 1154779791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154779791 NPI number — MILWAUKIE CHIROPRACTIC - DR. JESSE BROCKEY LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MILWAUKIE CHIROPRACTIC - DR. JESSE BROCKEY 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:
COLUMBIA PACIFIC CHIROPRACTIC
Provider Other Organization Name Type Code:
3
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:
1154779791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/24/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 576
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WARRENTON
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97146-0576
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-861-1661
Provider Business Mailing Address Fax Number:
503-861-0254

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
679 E HARBOR DR
Provider Second Line Business Practice Location Address:
#140
Provider Business Practice Location Address City Name:
WARRENTON
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97146-9717
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-861-1661
Provider Business Practice Location Address Fax Number:
503-861-0254
Provider Enumeration Date:
05/24/2016

Additional Information

Authorized Official

Authorized Official Last Name:
BROCKEY
Authorized Official First Name:
JESSE
Authorized Official Middle Name:
OWEN
Authorized Official Title or Position:
OWNER/CHIROPRACTOR
Authorized Official Telephone Number:
503-861-1661

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5008 , 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: R172616 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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