Provider Demographics
NPI:1376563106
Name:CONKLIN CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:CONKLIN CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:L
Authorized Official - Last Name:CONKLIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC CCST
Authorized Official - Phone:503-287-6199
Mailing Address - Street 1:707 NE KNOTT ST
Mailing Address - Street 2:STE 101
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97212
Mailing Address - Country:US
Mailing Address - Phone:503-287-6199
Mailing Address - Fax:503-287-0210
Practice Address - Street 1:707 NE KNOTT ST
Practice Address - Street 2:STE 101
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97212
Practice Address - Country:US
Practice Address - Phone:503-287-6199
Practice Address - Fax:503-287-0210
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR272568111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR116888OtherGROUP PIN #
OR116889Medicare ID - Type UnspecifiedPROVIDER #
OR116888OtherGROUP PIN #