Provider Demographics
NPI:1649446998
Name:KEREAH CARPENTER DC PC
Entity type:Organization
Organization Name:KEREAH CARPENTER DC PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KEREAH
Authorized Official - Middle Name:
Authorized Official - Last Name:CARPENTER
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-642-3423
Mailing Address - Street 1:14355 SW ALLEN BLVD
Mailing Address - Street 2:STE 100
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-4700
Mailing Address - Country:US
Mailing Address - Phone:503-642-3423
Mailing Address - Fax:
Practice Address - Street 1:14355 SW ALLEN BLVD
Practice Address - Street 2:STE 100
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-4700
Practice Address - Country:US
Practice Address - Phone:503-642-3423
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-07
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2818111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR27 2818OtherOREGON BOARD OF CHIROPRACTIC EXAMINERS
OR116900Medicaid
OR050065000OtherBLUE CROSS BLUE SHIELD
OR0000QGFWNMedicare PIN