Provider Demographics
NPI:1780835132
Name:GRANDE RONDE CHIROPRACTIC CLINIC, LLC
Entity Type:Organization
Organization Name:GRANDE RONDE CHIROPRACTIC CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:A
Authorized Official - Last Name:MCKEOWN
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-963-0339
Mailing Address - Street 1:1116 J AVE
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2073
Mailing Address - Country:US
Mailing Address - Phone:541-963-0339
Mailing Address - Fax:541-663-8882
Practice Address - Street 1:1116 J AVE
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2073
Practice Address - Country:US
Practice Address - Phone:541-963-0339
Practice Address - Fax:541-663-8882
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-03
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3792111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty