Provider Demographics
NPI:1578548566
Name:PROM, STEVEN JOHN (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:JOHN
Last Name:PROM
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1659 NE MARKET DR
Mailing Address - Street 2:
Mailing Address - City:FAIRVIEW
Mailing Address - State:OR
Mailing Address - Zip Code:97024-3867
Mailing Address - Country:US
Mailing Address - Phone:503-465-9100
Mailing Address - Fax:503-665-2290
Practice Address - Street 1:1659 NE MARKET DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW
Practice Address - State:OR
Practice Address - Zip Code:97024-3867
Practice Address - Country:US
Practice Address - Phone:503-465-9100
Practice Address - Fax:503-665-2290
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3096111N00000X
HI932111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
106267Medicare ID - Type Unspecified
U78749Medicare UPIN