1669862256 NPI number — VANDERLOO CHIROPRACTIC LLC

Table of content: (NPI 1669862256)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669862256 NPI number — VANDERLOO CHIROPRACTIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VANDERLOO CHIROPRACTIC 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:
6
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:
1669862256
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/03/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2230 W BURNSIDE ST STE D
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PORTLAND
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97210-3727
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
971-255-1922
Provider Business Mailing Address Fax Number:
971-250-2884

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2230 W BURNSIDE ST STE D
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PORTLAND
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97210-3727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
971-255-1922
Provider Business Practice Location Address Fax Number:
971-250-2884
Provider Enumeration Date:
02/03/2015

Additional Information

Authorized Official

Authorized Official Last Name:
VANDERLOO
Authorized Official First Name:
LANCE
Authorized Official Middle Name:
RICHARD
Authorized Official Title or Position:
CHIROPRACTOR / OWNER
Authorized Official Telephone Number:
971-255-1922

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  5567 , 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: G8913150 . This is a "MEDICARE PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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