Provider Demographics
NPI:1134393556
Name:PORTLAND CHIROPRACTIC GROUP INC
Entity type:Organization
Organization Name:PORTLAND CHIROPRACTIC GROUP INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:HEWITT
Authorized Official - Suffix:
Authorized Official - Credentials:DC, CCSP
Authorized Official - Phone:503-224-2100
Mailing Address - Street 1:2031 E BURNSIDE ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97214-1649
Mailing Address - Country:US
Mailing Address - Phone:503-224-2100
Mailing Address - Fax:503-224-2129
Practice Address - Street 1:2031 E BURNSIDE ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97214-1649
Practice Address - Country:US
Practice Address - Phone:503-224-2100
Practice Address - Fax:503-224-2129
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-16
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2473111NP0017X
OR1527171100000X
OR7732225700000X
OR2343111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No111NP0017XChiropractic ProvidersChiropractorPediatric ChiropractorGroup - Single Specialty
No171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGFHHMedicare UPIN