Provider Demographics
NPI:1407875594
Name:MOURSALIAN, SAM SARKIS (DC)
Entity Type:Individual
Prefix:DR
First Name:SAM
Middle Name:SARKIS
Last Name:MOURSALIAN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3455 LANCASTER DR NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-1357
Mailing Address - Country:US
Mailing Address - Phone:503-779-4243
Mailing Address - Fax:
Practice Address - Street 1:3455 LANCASTER DR NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97305-1357
Practice Address - Country:US
Practice Address - Phone:503-779-4243
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR71 3607111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR005708Medicaid
OR865556000OtherREGENCE BLUE CROSS
OR133810Medicare ID - Type UnspecifiedNORIDIAN
OR865556000OtherREGENCE BLUE CROSS