Provider Demographics
NPI:1417131301
Name:PACIFIC CREST CHIROPRACTIC AND WELLNESS CENTER PC
Entity Type:Organization
Organization Name:PACIFIC CREST CHIROPRACTIC AND WELLNESS CENTER PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:TODD
Authorized Official - Middle Name:J
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-464-0808
Mailing Address - Street 1:2270 NW TROOST ST
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6006
Mailing Address - Country:US
Mailing Address - Phone:541-464-0808
Mailing Address - Fax:541-464-0809
Practice Address - Street 1:2270 NW TROOST ST
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-6006
Practice Address - Country:US
Practice Address - Phone:541-464-0808
Practice Address - Fax:541-464-0809
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-27
Last Update Date:2008-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273045111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR114212Medicare PIN