Provider Demographics
NPI:1982851978
Name:KING PROFESSIONAL CHIROPRACTIC CARE PC
Entity Type:Organization
Organization Name:KING PROFESSIONAL CHIROPRACTIC CARE PC
Other - Org Name:KING CHIROPRACTIC CLINIC SE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:ROSS
Authorized Official - Last Name:KING
Authorized Official - Suffix:JR
Authorized Official - Credentials:DC
Authorized Official - Phone:503-761-9076
Mailing Address - Street 1:15348 SE DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97236-2345
Mailing Address - Country:US
Mailing Address - Phone:503-761-9076
Mailing Address - Fax:503-761-9679
Practice Address - Street 1:15348 SE DIVISION ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97236-2345
Practice Address - Country:US
Practice Address - Phone:503-761-9076
Practice Address - Fax:503-761-9679
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1386111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT87399Medicare UPIN
OR0000QGBMGMedicare PIN