Provider Demographics
NPI:1073980546
Name:KEVIN MICHAEL PHILLIPS DC PC
Entity Type:Organization
Organization Name:KEVIN MICHAEL PHILLIPS DC PC
Other - Org Name:HEARTSTONE FAMILY CHIROPRACTIC
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-385-1819
Mailing Address - Street 1:112 NW GREELEY AVE
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97703-2914
Mailing Address - Country:US
Mailing Address - Phone:541-385-1819
Mailing Address - Fax:
Practice Address - Street 1:112 NW GREELEY AVE
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97703-2914
Practice Address - Country:US
Practice Address - Phone:541-385-1819
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-31
Last Update Date:2015-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3317111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty