Provider Demographics
NPI:1417233560
Name:KRUSE PARK CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:KRUSE PARK CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:M
Authorized Official - Last Name:GALLIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-635-1236
Mailing Address - Street 1:3990 COLLINS WAY
Mailing Address - Street 2:201
Mailing Address - City:LAKE OSWEGO
Mailing Address - State:OR
Mailing Address - Zip Code:97035-3459
Mailing Address - Country:US
Mailing Address - Phone:503-635-1236
Mailing Address - Fax:503-697-4741
Practice Address - Street 1:3990 COLLINS WAY
Practice Address - Street 2:201
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3459
Practice Address - Country:US
Practice Address - Phone:503-635-1236
Practice Address - Fax:503-697-4741
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-02
Last Update Date:2012-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1674111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR109099OtherMEDICARE PTAN