Provider Demographics
NPI:1861677783
Name:PINE TREE CHIROPRACTIC PC
Entity Type:Organization
Organization Name:PINE TREE CHIROPRACTIC PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:G
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:541-883-2225
Mailing Address - Street 1:2515 CROSBY AVE
Mailing Address - Street 2:
Mailing Address - City:KLAMATH FALLS
Mailing Address - State:OR
Mailing Address - Zip Code:97603-4553
Mailing Address - Country:US
Mailing Address - Phone:541-883-2225
Mailing Address - Fax:541-882-9388
Practice Address - Street 1:2515 CROSBY AVE
Practice Address - Street 2:
Practice Address - City:KLAMATH FALLS
Practice Address - State:OR
Practice Address - Zip Code:97603-4553
Practice Address - Country:US
Practice Address - Phone:541-883-2225
Practice Address - Fax:541-882-9388
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-09
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR0700001797111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR115214Medicare PIN
ORU58937Medicare UPIN