Provider Demographics
NPI:1770625097
Name:KHALSA CHIROPRACTIC CLINIC P C
Entity type:Organization
Organization Name:KHALSA CHIROPRACTIC CLINIC P C
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:GURUKA
Authorized Official - Middle Name:
Authorized Official - Last Name:KHALSA
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-587-7431
Mailing Address - Street 1:695 COMMERCIAL ST SE
Mailing Address - Street 2:SUITE 114
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97301-3431
Mailing Address - Country:US
Mailing Address - Phone:503-362-2623
Mailing Address - Fax:503-362-2558
Practice Address - Street 1:695 COMMERCIAL ST SE
Practice Address - Street 2:SUITE 114
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-3431
Practice Address - Country:US
Practice Address - Phone:503-362-2623
Practice Address - Fax:503-362-2558
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-13
Last Update Date:2011-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27-2079111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67793Medicare UPIN
OR112553Medicare ID - Type Unspecified