Provider Demographics
NPI:1184862807
Name:KHALSA PAIN RELIEF CLINIC, P.C.
Entity Type:Organization
Organization Name:KHALSA PAIN RELIEF CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCE /RECORD MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AMY
Authorized Official - Middle Name:
Authorized Official - Last Name:WONG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-238-1032
Mailing Address - Street 1:5013 SE HAWTHORNE BLVD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97215-3255
Mailing Address - Country:US
Mailing Address - Phone:503-238-1032
Mailing Address - Fax:503-233-1916
Practice Address - Street 1:5013 SE HAWTHORNE BLVD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97215-3255
Practice Address - Country:US
Practice Address - Phone:503-238-1032
Practice Address - Fax:503-233-1916
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-03
Last Update Date:2009-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1809111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000QGCGNMedicare PIN