MEDICARE: DR. KELLY MARY BALTAZAR N.D., D.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	111N00000X	Chiropractor	5843	OR
2	175F00000X	Naturopath	4063	OR

General Provider Information

NPI Number	:	1669670550
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. KELLY MARY BALTAZAR N.D., D.C.

Provider Business Mailing Address
First Line	:	7425 SW ALOMA WAY APT 1
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97223-7919
Country	:	US
Telephone Number	:	425-269-8187
Fax Number	:

Provider Business Practice Location Address
First Line	:	3025 SW CORBETT AVE
Second Line	:
City	:	PORTLAND
State	:	OR
Zip	:	97201-4858
Country	:	US
Telephone Number	:	503-552-1551
Fax Number	:	503-226-8133

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/03/2007
Last Update Date	:	07/21/2022

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