Provider Demographics
NPI:1063674679
Name:KELSALL CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:KELSALL CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:BURGESS
Authorized Official - Suffix:
Authorized Official - Credentials:OFFICE MANAGER
Authorized Official - Phone:503-223-8719
Mailing Address - Street 1:1615 NW 23RD AVE
Mailing Address - Street 2:SUITE 2
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97210-2563
Mailing Address - Country:US
Mailing Address - Phone:503-223-8719
Mailing Address - Fax:503-223-3237
Practice Address - Street 1:1615 NW 23RD AVE
Practice Address - Street 2:SUITE 2
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97210-2563
Practice Address - Country:US
Practice Address - Phone:503-223-8719
Practice Address - Fax:503-223-3237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-26
Last Update Date:2008-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2997111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NS0005XChiropractic ProvidersChiropractorSports PhysicianGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
R100924OtherMEDICARE PROVIDER ID
ORU64819Medicare UPIN
OR134346Medicare PIN