Provider Demographics
NPI:1265504286
Name:TILLAMOOK CHIROPRACTIC INCORPORATED
Entity Type:Organization
Organization Name:TILLAMOOK CHIROPRACTIC INCORPORATED
Other - Org Name:TILLAMOOK CHIROPRACTIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:S
Authorized Official - Last Name:WAXTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-842-5951
Mailing Address - Street 1:312 LAUREL AVE
Mailing Address - Street 2:
Mailing Address - City:TILLAMOOK
Mailing Address - State:OR
Mailing Address - Zip Code:97141-2314
Mailing Address - Country:US
Mailing Address - Phone:503-842-5951
Mailing Address - Fax:503-842-5104
Practice Address - Street 1:312 LAUREL AVE
Practice Address - Street 2:
Practice Address - City:TILLAMOOK
Practice Address - State:OR
Practice Address - Zip Code:97141-2314
Practice Address - Country:US
Practice Address - Phone:503-842-5951
Practice Address - Fax:503-842-5104
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273157111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR155857Medicare UPIN