Provider Demographics
NPI:1578717104
Name:STALLER, CARRIE (DC)
Entity Type:Individual
Prefix:
First Name:CARRIE
Middle Name:
Last Name:STALLER
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5308 SE RHONE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97206-2962
Mailing Address - Country:US
Mailing Address - Phone:503-775-6885
Mailing Address - Fax:503-775-2451
Practice Address - Street 1:5308 SE RHONE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206-2962
Practice Address - Country:US
Practice Address - Phone:503-775-6885
Practice Address - Fax:503-775-2451
Is Sole Proprietor?:No
Enumeration Date:2008-11-10
Last Update Date:2013-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH 9597111N00000X
OR5101111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor