Healthcare Provider Details

I. General information

NPI: 1003092248
Provider Name (Legal Business Name): MARK ANTHONY BETSILL D.C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23479 SE STARK ST STE 101
GRESHAM OR
97030-2962
US

IV. Provider business mailing address

23479 SE STARK ST STE 101
GRESHAM OR
97030-2962
US

V. Phone/Fax

Practice location:
  • Phone: 503-618-0147
  • Fax: 503-618-0148
Mailing address:
  • Phone: 503-618-0147
  • Fax: 503-618-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number4022
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: