Provider Demographics
NPI:1093843302
Name:VISSERS, MICHAEL JAY (DC)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:JAY
Last Name:VISSERS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 N VINE ST
Mailing Address - Street 2:
Mailing Address - City:CANBY
Mailing Address - State:OR
Mailing Address - Zip Code:97013-2571
Mailing Address - Country:US
Mailing Address - Phone:503-263-8053
Mailing Address - Fax:
Practice Address - Street 1:130 SW 2ND AVE STE 101
Practice Address - Street 2:
Practice Address - City:CANBY
Practice Address - State:OR
Practice Address - Zip Code:97013-4156
Practice Address - Country:US
Practice Address - Phone:503-263-3033
Practice Address - Fax:503-263-3023
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-28
Last Update Date:2007-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-3072111N00000X
CA20436111N00000X
CO4556111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR113726Medicare ID - Type Unspecified