Provider Demographics
NPI:1760756472
Name:SANDY CHIROPRACTIC CLINIC
Entity Type:Organization
Organization Name:SANDY CHIROPRACTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:EDWIN
Authorized Official - Last Name:HYLAND
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-668-5822
Mailing Address - Street 1:PO BOX 642
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:OR
Mailing Address - Zip Code:97055-0642
Mailing Address - Country:US
Mailing Address - Phone:503-668-5822
Mailing Address - Fax:
Practice Address - Street 1:38953 PIONEER BLVD.
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:OR
Practice Address - Zip Code:97055
Practice Address - Country:US
Practice Address - Phone:503-668-5822
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-27
Last Update Date:2012-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORROOOOQGCQVMedicare UPIN