Provider Demographics
NPI:1407320435
Name:ELITE MEDICAL CENTER CHIROPRACTIC & MASSAGE
Entity Type:Organization
Organization Name:ELITE MEDICAL CENTER CHIROPRACTIC & MASSAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ALEXI
Authorized Official - Middle Name:
Authorized Official - Last Name:GUDISHVILI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-509-4840
Mailing Address - Street 1:1350 SE 122ND AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97233-1203
Mailing Address - Country:US
Mailing Address - Phone:503-889-0906
Mailing Address - Fax:503-894-9557
Practice Address - Street 1:1350 SE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97233-1203
Practice Address - Country:US
Practice Address - Phone:503-889-0906
Practice Address - Fax:503-894-9557
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-01-12
Last Update Date:2023-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty