Provider Demographics
NPI:1780041657
Name:GLOECKNER, RYAN MICHAEL (DC)
Entity type:Individual
Prefix:DR
First Name:RYAN
Middle Name:MICHAEL
Last Name:GLOECKNER
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 1:200 NE 20TH AVE STE 20
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97232-3094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 NE 20TH AVE STE 20
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97232-3094
Practice Address - Country:US
Practice Address - Phone:971-229-1384
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-24
Last Update Date:2024-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDC-1601111N00000X
OR5704111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor