Provider Demographics
NPI:1578702106
Name:PETROTTA CHIROPRACTIC INC.
Entity Type:Organization
Organization Name:PETROTTA CHIROPRACTIC INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:DR
Authorized Official - First Name:DEBORAH
Authorized Official - Middle Name:A
Authorized Official - Last Name:PETROTTA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-625-4054
Mailing Address - Street 1:PO BOX 1483
Mailing Address - Street 2:
Mailing Address - City:SHERWOOD
Mailing Address - State:OR
Mailing Address - Zip Code:97140-1483
Mailing Address - Country:US
Mailing Address - Phone:503-625-4054
Mailing Address - Fax:
Practice Address - Street 1:22021 SW SHERWOOD BLVD
Practice Address - Street 2:
Practice Address - City:SHERWOOD
Practice Address - State:OR
Practice Address - Zip Code:97140-9327
Practice Address - Country:US
Practice Address - Phone:503-625-4054
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-04
Last Update Date:2009-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2963111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGHJKMedicare PIN