Provider Demographics
NPI:1851533087
Name:WILSONVILLE CHIROPRACTIC CLINIC, P.C.
Entity Type:Organization
Organization Name:WILSONVILLE CHIROPRACTIC CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:BURT
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-682-9046
Mailing Address - Street 1:PO BOX 691
Mailing Address - Street 2:
Mailing Address - City:WILSONVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97070-0691
Mailing Address - Country:US
Mailing Address - Phone:503-682-9046
Mailing Address - Fax:503-682-9046
Practice Address - Street 1:30045 SW PARKWAY AVE
Practice Address - Street 2:
Practice Address - City:WILSONVILLE
Practice Address - State:OR
Practice Address - Zip Code:97070-9735
Practice Address - Country:US
Practice Address - Phone:503-682-9046
Practice Address - Fax:503-682-9046
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-02
Last Update Date:2009-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1544111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty