Provider Demographics
NPI:1922473719
Name:AMPLIFE CHIROPRACTIC AND SPORTS CHIROPRACTIC
Entity Type:Organization
Organization Name:AMPLIFE CHIROPRACTIC AND SPORTS CHIROPRACTIC
Other - Org Name:AMPLIFE CHIROPRACTIC AND SPORTS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:TYLER
Authorized Official - Middle Name:JOSEPH
Authorized Official - Last Name:BURKE
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:208-340-1573
Mailing Address - Street 1:16548 NE HALSEY ST APT 113
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-8612
Mailing Address - Country:US
Mailing Address - Phone:208-340-1573
Mailing Address - Fax:
Practice Address - Street 1:355 NE 223RD AVE
Practice Address - Street 2:
Practice Address - City:GRESHAM
Practice Address - State:OR
Practice Address - Zip Code:97030-8554
Practice Address - Country:US
Practice Address - Phone:208-340-1573
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-05
Last Update Date:2016-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR5657111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty