Provider Demographics
NPI:1942588785
Name:LIFESTREAMS CHIROPRACTIC CENTER, LLC
Entity Type:Organization
Organization Name:LIFESTREAMS CHIROPRACTIC CENTER, LLC
Other - Org Name:MARY ANN TACK, DC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIROPRACTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARY ANN
Authorized Official - Middle Name:
Authorized Official - Last Name:TACK
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-537-2052
Mailing Address - Street 1:901 BRUTSCHER ST STE 210
Mailing Address - Street 2:
Mailing Address - City:NEWBERG
Mailing Address - State:OR
Mailing Address - Zip Code:97132-6094
Mailing Address - Country:US
Mailing Address - Phone:503-537-2052
Mailing Address - Fax:503-538-8315
Practice Address - Street 1:901 BRUTSCHER ST STE 210
Practice Address - Street 2:
Practice Address - City:NEWBERG
Practice Address - State:OR
Practice Address - Zip Code:97132-6094
Practice Address - Country:US
Practice Address - Phone:503-537-2052
Practice Address - Fax:503-538-8315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-27
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
111N00000X
OR2863261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No261Q00000XAmbulatory Health Care FacilitiesClinic/CenterGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGHFPOtherMEDICARE ID TYPE UNSPECIFIED
OR274833Medicaid