1174839989 NPI number — WELLSPRING CHIROPRACTIC, PC

Table of content: (NPI 1174839989)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174839989 NPI number — WELLSPRING CHIROPRACTIC, PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPRING CHIROPRACTIC, 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:
1174839989
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/31/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
165 N 11TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAINT HELENS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97051-1803
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
503-397-2202
Provider Business Mailing Address Fax Number:
503-397-7113

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 N 11TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAINT HELENS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97051-1803
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
503-397-2202
Provider Business Practice Location Address Fax Number:
503-397-7113
Provider Enumeration Date:
08/31/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MCCAUSLAND
Authorized Official First Name:
KEVIN
Authorized Official Middle Name:
LEE
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
503-397-2202

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  2864 , 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: R102662 . This is a "MEDICARE (UNSURE IWHAT OPTION ABOVE APPLIES)" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com