Provider Demographics
NPI:1700363389
Name:KRUSE PARK CHIROPRACTIC LLC
Entity Type:Organization
Organization Name:KRUSE PARK CHIROPRACTIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:BRONWYN
Authorized Official - Middle Name:
Authorized Official - Last Name:ILLINGWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:DC, MS, BS
Authorized Official - Phone:503-593-4719
Mailing Address - Street 1:PO BOX 1609
Mailing Address - Street 2:
Mailing Address - City:LAKE GROVE
Mailing Address - State:OR
Mailing Address - Zip Code:97035-0809
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3990 COLLINS WAY STE 201
Practice Address - Street 2:
Practice Address - City:LAKE OSWEGO
Practice Address - State:OR
Practice Address - Zip Code:97035-3459
Practice Address - Country:US
Practice Address - Phone:503-635-1236
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-26
Last Update Date:2018-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3897111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty