Provider Demographics
NPI:1003198185
Name:BEAUMONT CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:BEAUMONT CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:FRANK
Authorized Official - Middle Name:M
Authorized Official - Last Name:PRIDEAUX
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-287-6666
Mailing Address - Street 1:4211 NE FREMONT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1149
Mailing Address - Country:US
Mailing Address - Phone:503-287-6666
Mailing Address - Fax:503-287-1390
Practice Address - Street 1:4211 NE FREMONT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1149
Practice Address - Country:US
Practice Address - Phone:503-287-6666
Practice Address - Fax:503-287-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-09-14
Last Update Date:2011-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271448111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT68021Medicare UPIN