Provider Demographics
NPI:1326211673
Name:MY FAMILY CHIROPRACTOR, LLC
Entity Type:Organization
Organization Name:MY FAMILY CHIROPRACTOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DOCTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:DESJARDINS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-666-2298
Mailing Address - Street 1:16409 SE DIVISION ST
Mailing Address - Street 2:SUITE 216, PMB 285
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-1931
Mailing Address - Country:US
Mailing Address - Phone:503-666-2298
Mailing Address - Fax:503-492-2355
Practice Address - Street 1:655 NW BURNSIDE RD STE 5
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-3745
Practice Address - Country:US
Practice Address - Phone:503-666-2298
Practice Address - Fax:503-492-2355
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-08
Last Update Date:2009-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3243261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1059020OtherASH DOC ID
1215008834OtherINDIVIDUAL NPI
OR111278Medicare PIN