Provider Demographics
NPI:1700904497
Name:ELLSWORTH, STEVEN (DC)
Entity Type:Individual
Prefix:DR
First Name:STEVEN
Middle Name:
Last Name:ELLSWORTH
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7100 SW HAMPTON ST STE 140
Mailing Address - Street 2:
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223-8375
Mailing Address - Country:US
Mailing Address - Phone:503-639-5773
Mailing Address - Fax:503-684-8115
Practice Address - Street 1:7100 SW HAMPTON ST STE 140
Practice Address - Street 2:
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223-8375
Practice Address - Country:US
Practice Address - Phone:503-639-5773
Practice Address - Fax:503-684-8115
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR2338111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR0000QGFHGMedicare ID - Type UnspecifiedMEDICARE
ORT95372Medicare UPIN