Provider Demographics
NPI:1639466386
Name:DR. JOHN O. RENQUIST
Entity type:Organization
Organization Name:DR. JOHN O. RENQUIST
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DOCTOR OF CHIROPRACTIC
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:O
Authorized Official - Last Name:RENQUIST
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-585-1282
Mailing Address - Street 1:1095 LIBERTY ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-4140
Mailing Address - Country:US
Mailing Address - Phone:503-585-1282
Mailing Address - Fax:503-585-5531
Practice Address - Street 1:1095 LIBERTY ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-4140
Practice Address - Country:US
Practice Address - Phone:503-585-1282
Practice Address - Fax:503-585-5531
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-07-01
Last Update Date:2011-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1348111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR0000QGBQNMedicare PIN