Provider Demographics
NPI:1346347929
Name:TACK, MARY ANN (DC)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:TACK
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 BRUTSCHER ST
Mailing Address - Street 2:STE 210
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6095
Mailing Address - Country:US
Mailing Address - Phone:503-537-2052
Mailing Address - Fax:503-538-8315
Practice Address - Street 1:901 BRUTSCHER ST
Practice Address - Street 2:STE 210
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6095
Practice Address - Country:US
Practice Address - Phone:503-537-2052
Practice Address - Fax:503-538-8315
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-17
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2863111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR274833Medicaid