Healthcare Provider Details

I. General information

NPI: 1922473719
Provider Name (Legal Business Name): AMPLIFE CHIROPRACTIC AND SPORTS CHIROPRACTIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2015
Last Update Date: 01/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 NE 223RD AVE
GRESHAM OR
97030-8554
US

IV. Provider business mailing address

16548 NE HALSEY ST APT 113
PORTLAND OR
97230-8612
US

V. Phone/Fax

Practice location:
  • Phone: 208-340-1573
  • Fax:
Mailing address:
  • Phone: 208-340-1573
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number5657
License Number StateOR

VIII. Authorized Official

Name: DR. TYLER JOSEPH BURKE
Title or Position: OWNER
Credential: DC
Phone: 208-340-1573