Provider Demographics
NPI:1881876704
Name:CORNERSTONE CHIROPRACTIC, LLC
Entity type:Organization
Organization Name:CORNERSTONE CHIROPRACTIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIROPRACTOR, OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:DRAKE
Authorized Official - Last Name:TOLLENAAR
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-639-0778
Mailing Address - Street 1:11565 SW DURHAM RD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97224-3553
Mailing Address - Country:US
Mailing Address - Phone:503-639-0778
Mailing Address - Fax:503-639-0815
Practice Address - Street 1:11565 SW DURHAM RD
Practice Address - Street 2:SUITE 110
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97224-3553
Practice Address - Country:US
Practice Address - Phone:503-639-0778
Practice Address - Fax:503-639-0815
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2011-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27 2904111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR110227Medicare PIN