Provider Demographics
NPI:1679850010
Name:MILWAUKIE SPINE AND SPORT, LLC
Entity Type:Organization
Organization Name:MILWAUKIE SPINE AND SPORT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:
Authorized Official - Last Name:BARANICK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-344-6711
Mailing Address - Street 1:2100 SE LAKE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MILWAUKIE
Mailing Address - State:OR
Mailing Address - Zip Code:97222-7759
Mailing Address - Country:US
Mailing Address - Phone:503-344-6711
Mailing Address - Fax:503-926-9365
Practice Address - Street 1:2100 SE LAKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97222-7759
Practice Address - Country:US
Practice Address - Phone:503-344-6711
Practice Address - Fax:503-926-9365
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-14
Last Update Date:2013-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3998261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service