Provider Demographics
NPI:1235302795
Name:CHIROPRACTIC LIFE CENTER PC
Entity Type:Organization
Organization Name:CHIROPRACTIC LIFE CENTER PC
Other - Org Name:CHIROPRACTIC LIFE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:RONALD
Authorized Official - Last Name:JOHANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-255-7746
Mailing Address - Street 1:12762 SE STARK ST
Mailing Address - Street 2:PLAZA 125, BLDG D
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1539
Mailing Address - Country:US
Mailing Address - Phone:503-255-7746
Mailing Address - Fax:503-255-0818
Practice Address - Street 1:12762 SE STARK ST
Practice Address - Street 2:PLAZA 125, BLDG D
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1539
Practice Address - Country:US
Practice Address - Phone:503-255-7746
Practice Address - Fax:503-255-0818
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-04
Last Update Date:2019-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271737111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedicGroup - Single Specialty