Provider Demographics
NPI:1437208303
Name:HEALTHLETICS CHIROPRACTIC CLINIC LLC
Entity Type:Organization
Organization Name:HEALTHLETICS CHIROPRACTIC CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR AND MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:OKERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-758-9393
Mailing Address - Street 1:2005 NW GRANT AVE
Mailing Address - Street 2:
Mailing Address - City:CORVALLIS
Mailing Address - State:OR
Mailing Address - Zip Code:97330-4366
Mailing Address - Country:US
Mailing Address - Phone:503-449-4945
Mailing Address - Fax:541-738-0704
Practice Address - Street 1:2005 NW GRANT AVE
Practice Address - Street 2:
Practice Address - City:CORVALLIS
Practice Address - State:OR
Practice Address - Zip Code:97330-4366
Practice Address - Country:US
Practice Address - Phone:503-449-4945
Practice Address - Fax:541-738-0704
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-09
Last Update Date:2007-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3661261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center