Provider Demographics
NPI:1992830681
Name:PORTLAND CHIROPRACTIC CENTER, LTD.
Entity Type:Organization
Organization Name:PORTLAND CHIROPRACTIC CENTER, LTD.
Other - Org Name:ADOBE CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:E
Authorized Official - Last Name:HAWKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:361-813-6238
Mailing Address - Street 1:4535 SOUTH PADRE ISLAND DRIVE
Mailing Address - Street 2:STE. 12
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78411-4436
Mailing Address - Country:US
Mailing Address - Phone:361-854-7748
Mailing Address - Fax:361-356-3975
Practice Address - Street 1:4535 SOUTH PADRE ISLAND DRIVE
Practice Address - Street 2:STE. 12
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78411-4436
Practice Address - Country:US
Practice Address - Phone:361-854-7748
Practice Address - Fax:361-356-3975
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-22
Last Update Date:2012-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9414111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0059NJOtherBCBS