Healthcare Provider Details

I. General information

NPI: 1578701082
Provider Name (Legal Business Name): ELITE HEALTH CARE DBA ELITE CHIROPRACTIC AND WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 07/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23440 SE STARK ST
GRESHAM OR
97030-2961
US

IV. Provider business mailing address

23440 SE STARK ST
GRESHAM OR
97030-2961
US

V. Phone/Fax

Practice location:
  • Phone: 503-489-6245
  • Fax: 503-489-0552
Mailing address:
  • Phone: 503-489-6245
  • Fax: 503-489-0552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3726
License Number StateOR

VIII. Authorized Official

Name: MRS. HEIDI A WALTER
Title or Position: OFFICE MANAGER
Credential:
Phone: 503-489-6245