Provider Demographics
NPI:1619140506
Name:SCAPPOOSE CHIROPRACTIC CLINIC PC
Entity Type:Organization
Organization Name:SCAPPOOSE CHIROPRACTIC CLINIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:DOMBY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-543-3195
Mailing Address - Street 1:PO BOX 1108
Mailing Address - Street 2:
Mailing Address - City:SCAPPOOSE
Mailing Address - State:OR
Mailing Address - Zip Code:97056-1108
Mailing Address - Country:US
Mailing Address - Phone:503-543-3195
Mailing Address - Fax:503-543-7532
Practice Address - Street 1:52481 SW 1ST STREET
Practice Address - Street 2:
Practice Address - City:SCAPPOOSE
Practice Address - State:OR
Practice Address - Zip Code:97056
Practice Address - Country:US
Practice Address - Phone:503-543-3195
Practice Address - Fax:503-543-7532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-11
Last Update Date:2008-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2310261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGFBVMedicare UPIN