Provider Demographics
NPI:1932356557
Name:ROSE CITY CHIROPRACTIC CLINIC INC
Entity Type:Organization
Organization Name:ROSE CITY CHIROPRACTIC CLINIC INC
Other - Org Name:JEROME M. FLADOOS DC
Other - Org Type:Other Name
Authorized Official - Title/Position:CHIROPRACTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:M
Authorized Official - Last Name:FLADOOS
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:503-252-2533
Mailing Address - Street 1:12508 NE HALSEY ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230
Mailing Address - Country:US
Mailing Address - Phone:503-252-2533
Mailing Address - Fax:503-252-2532
Practice Address - Street 1:12508 NE HALSEY ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-1929
Practice Address - Country:US
Practice Address - Phone:503-252-2533
Practice Address - Fax:503-252-2532
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-08-26
Last Update Date:2008-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR1300111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORT67611Medicare UPIN
OR0000QGBKFMedicare PIN