Provider Demographics
NPI:1558392019
Name:RONALD M CROCKETT BS DC PC
Entity Type:Organization
Organization Name:RONALD M CROCKETT BS DC PC
Other - Org Name:CROCKETT CHIROPRACTIC CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:CROCKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-371-9796
Mailing Address - Street 1:4070 MACLEAY RD SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97317-5801
Mailing Address - Country:US
Mailing Address - Phone:503-371-9796
Mailing Address - Fax:503-371-8265
Practice Address - Street 1:4070 MACLEAY RD SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97317-5801
Practice Address - Country:US
Practice Address - Phone:503-371-9796
Practice Address - Fax:503-371-8265
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RONALD M CROCKETT BS DC PC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-05
Last Update Date:2012-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1472111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR114500Medicare ID - Type UnspecifiedGRP NUMBER
ORR114501Medicare ID - Type UnspecifiedPROV NUMBER
T67544Medicare UPIN