Provider Demographics
NPI:1720110794
Name:DYSON FAMILY CHIROPRACTIC CENTER, P.C.
Entity Type:Organization
Organization Name:DYSON FAMILY CHIROPRACTIC CENTER, P.C.
Other - Org Name:ADVANCED CHIROPRACTIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:G
Authorized Official - Last Name:DYSON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-361-3949
Mailing Address - Street 1:1295 WALLACE RD NW
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97304-3007
Mailing Address - Country:US
Mailing Address - Phone:503-361-3949
Mailing Address - Fax:
Practice Address - Street 1:1295 WALLACE RD NW
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97304-3007
Practice Address - Country:US
Practice Address - Phone:503-361-3949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-12
Last Update Date:2012-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3189111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR234885Medicaid
ORU81140Medicare UPIN
OR234885Medicaid