Provider Demographics
NPI:1407192891
Name:PELLERIN, JOHN MICHAEL JR (LMT)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MICHAEL
Last Name:PELLERIN
Suffix:JR
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21887 SW SHERWOOD BLVD STE A
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-9412
Mailing Address - Country:US
Mailing Address - Phone:503-625-0500
Mailing Address - Fax:503-625-0119
Practice Address - Street 1:21887 SW SHERWOOD BLVD STE A
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9412
Practice Address - Country:US
Practice Address - Phone:503-625-0500
Practice Address - Fax:503-625-0119
Is Sole Proprietor?:Yes
Enumeration Date:2012-12-12
Last Update Date:2012-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR17829111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor