1811222193 NPI number — PONDEROSA FAMILY CHIROPRACTIC

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 1811222193 NPI number — PONDEROSA FAMILY CHIROPRACTIC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PONDEROSA FAMILY CHIROPRACTIC
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:
1811222193
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 747
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SISTERS
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97759
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-588-6200
Provider Business Mailing Address Fax Number:
541-588-6201

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1011 DESPERADO TRAIL
Provider Second Line Business Practice Location Address:
STE 202
Provider Business Practice Location Address City Name:
SISTERS
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97759
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-588-6200
Provider Business Practice Location Address Fax Number:
541-588-6201
Provider Enumeration Date:
10/05/2009

Additional Information

Authorized Official

Authorized Official Last Name:
GREEN
Authorized Official First Name:
ANTHONY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
CHIROPRACTOR, OWNER
Authorized Official Telephone Number:
541-588-6200

Provider Taxonomy Codes

  • Taxonomy code: 111N00000X , with the licence number:  3756 , 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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