Provider Demographics
NPI:1790951440
Name:SHERIDAN FAMILY CHIROPRACTIC PC
Entity Type:Organization
Organization Name:SHERIDAN FAMILY CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-843-3888
Mailing Address - Street 1:PO BOX 37
Mailing Address - Street 2:
Mailing Address - City:SHERIDAN
Mailing Address - State:OR
Mailing Address - Zip Code:97378-0037
Mailing Address - Country:US
Mailing Address - Phone:503-843-3888
Mailing Address - Fax:503-843-4366
Practice Address - Street 1:639 W MAIN
Practice Address - Street 2:
Practice Address - City:SHERIDAN
Practice Address - State:OR
Practice Address - Zip Code:97378
Practice Address - Country:US
Practice Address - Phone:503-843-3888
Practice Address - Fax:503-843-4366
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2015-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR651343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR112941OtherPERMANENTE
059489000OtherREGENCE BC BS
OR112941OtherPERMANENTE
T67780Medicare UPIN