Provider Demographics
NPI:1952391088
Name:COLLISON, ERIC
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:
Last Name:COLLISON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1005 SE LAMBERT ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97202-6377
Mailing Address - Country:US
Mailing Address - Phone:503-235-4965
Mailing Address - Fax:
Practice Address - Street 1:1005 SE LAMBERT ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97202-6377
Practice Address - Country:US
Practice Address - Phone:503-235-4965
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-28
Last Update Date:2009-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR271776111N00000X
OR1776111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
R0000QGCMQMedicare PIN
OR0000QGCMQMedicare PIN