Provider Demographics
NPI:1619499266
Name:VISLOCKY, MADELYNN (DC)
Entity Type:Individual
Prefix:
First Name:MADELYNN
Middle Name:
Last Name:VISLOCKY
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 1:1010 SE 15TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-2612
Mailing Address - Country:US
Mailing Address - Phone:503-830-5934
Mailing Address - Fax:
Practice Address - Street 1:511 SW 10TH AVE STE 610
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97205-2707
Practice Address - Country:US
Practice Address - Phone:503-756-2743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-14
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5832111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor