Provider Demographics
NPI:1275523268
Name:INICE GOUGH DC PC
Entity Type:Organization
Organization Name:INICE GOUGH DC PC
Other - Org Name:THREE SISTERS CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:INICE
Authorized Official - Middle Name:D
Authorized Official - Last Name:GOUGH
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-549-3583
Mailing Address - Street 1:PO BOX 2178
Mailing Address - Street 2:
Mailing Address - City:SISTERS
Mailing Address - State:OR
Mailing Address - Zip Code:97759-2178
Mailing Address - Country:US
Mailing Address - Phone:541-549-3583
Mailing Address - Fax:541-549-3583
Practice Address - Street 1:270 S SPRUCE
Practice Address - Street 2:
Practice Address - City:SISTERS
Practice Address - State:OR
Practice Address - Zip Code:97759
Practice Address - Country:US
Practice Address - Phone:541-549-3583
Practice Address - Fax:541-549-3583
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-21
Last Update Date:2012-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272994111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR119014Medicare PIN