Provider Demographics
NPI:1255420139
Name:DOUGLASS, TREVOR STANLEY (DC, CCSP, MPH)
Entity type:Individual
Prefix:DR
First Name:TREVOR
Middle Name:STANLEY
Last Name:DOUGLASS
Suffix:
Gender:M
Credentials:DC, CCSP, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 BARNES AVE SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97306-1539
Mailing Address - Country:US
Mailing Address - Phone:971-209-2774
Mailing Address - Fax:
Practice Address - Street 1:462 17TH ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4223
Practice Address - Country:US
Practice Address - Phone:971-209-2774
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR273119111N00000X, 111NS0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
No111NS0005XChiropractic ProvidersChiropractorSports Physician
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR931265398Medicare UPIN
ORR103432Medicare ID - Type Unspecified