Provider Demographics
NPI:1831387380
Name:INTEGRATIVE CHIROPRACTIC & WELLNESS SPA, LLC
Entity type:Organization
Organization Name:INTEGRATIVE CHIROPRACTIC & WELLNESS SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTIC PHYSICIAN
Authorized Official - Prefix:MRS
Authorized Official - First Name:CYNDI
Authorized Official - Middle Name:ROZELLA
Authorized Official - Last Name:MYERS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:360-970-1416
Mailing Address - Street 1:9955 SE WASHINGTON ST
Mailing Address - Street 2:STE 320 # 6
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2439
Mailing Address - Country:US
Mailing Address - Phone:503-253-8818
Mailing Address - Fax:503-253-0377
Practice Address - Street 1:9955 SE WASHINGTON ST
Practice Address - Street 2:STE 320 #6
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2439
Practice Address - Country:US
Practice Address - Phone:503-253-8818
Practice Address - Fax:503-253-0377
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-10
Last Update Date:2007-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3748111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty