Provider Demographics
NPI:1164778692
Name:GREGG CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:GREGG CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:SEAN
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:GREGG
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-225-9033
Mailing Address - Street 1:4425 SW CORBETT AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-4260
Mailing Address - Country:US
Mailing Address - Phone:503-225-9033
Mailing Address - Fax:
Practice Address - Street 1:4425 SW CORBETT AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-4260
Practice Address - Country:US
Practice Address - Phone:503-225-9033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-08-02
Last Update Date:2012-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR4055261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center