Provider Demographics
NPI:1558410027
Name:NORTHWEST CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:NORTHWEST CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:OWEN
Authorized Official - Middle Name:D
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-471-0397
Mailing Address - Street 1:746 N.W. SIXTH STREET
Mailing Address - Street 2:
Mailing Address - City:GRANTS PASS
Mailing Address - State:OR
Mailing Address - Zip Code:97526-1524
Mailing Address - Country:US
Mailing Address - Phone:541-471-0397
Mailing Address - Fax:541-471-6459
Practice Address - Street 1:746 NW 6TH ST
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-1524
Practice Address - Country:US
Practice Address - Phone:541-471-0397
Practice Address - Fax:541-471-6459
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-10
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3563111N00000X
OR2821111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR101419Medicare ID - Type UnspecifiedDR. MARTIN
OR134195Medicare ID - Type UnspecifiedDR. SHONTZ
ORU42430Medicare UPIN
ORV08614Medicare UPIN