Healthcare Provider Details

I. General information

NPI: 1861754517
Provider Name (Legal Business Name): D'VIDA INJURY CLINIC & WELLNESS CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2012
Last Update Date: 06/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14195 SW ALLEN BLVD
BEAVERTON OR
97005-4408
US

IV. Provider business mailing address

14195 SW ALLEN BLVD
BEAVERTON OR
97005-4408
US

V. Phone/Fax

Practice location:
  • Phone: 503-626-2166
  • Fax: 503-641-6665
Mailing address:
  • Phone: 503-626-2166
  • Fax: 503-641-6665

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4077
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAC01279
License Number StateOR

VIII. Authorized Official

Name: MICHELLE WHITTAKER
Title or Position: OWNER
Credential: LAC
Phone: 503-626-2166