Healthcare Provider Details

I. General information

NPI: 1588991764
Provider Name (Legal Business Name): ANN MARIE KING D.C.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ANN MARIE KING TARR D.C.

II. Dates (important events)

Enumeration Date: 11/10/2009
Last Update Date: 09/22/2022
Certification Date: 09/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23479 SE STARK ST, SUITE 101
GRESHAM OR
97030
US

IV. Provider business mailing address

23479 SE STARK ST, SUITE 101
GRESHAM OR
97030
US

V. Phone/Fax

Practice location:
  • Phone: 360-903-1586
  • Fax: 503-618-0148
Mailing address:
  • Phone: 360-903-1586
  • Fax: 503-618-0148

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number3945
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3945
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: