Healthcare Provider Details

I. General information

NPI: 1265877856
Provider Name (Legal Business Name): ACTIVE OREGON CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2013
Last Update Date: 04/18/2023
Certification Date: 07/07/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 W CLARENDON ST
GLADSTONE OR
97027-2335
US

IV. Provider business mailing address

130 W CLARENDON ST
GLADSTONE OR
97027-2335
US

V. Phone/Fax

Practice location:
  • Phone: 503-655-2897
  • Fax: 503-655-2894
Mailing address:
  • Phone: 503-655-2897
  • Fax: 503-655-2854

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5140
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. STEPHANIE L TOLONEN
Title or Position: OWNER/CHIROPRACTIC PHYSICIAN
Credential: DC, MS
Phone: 503-655-2897