Healthcare Provider Details

I. General information

NPI: 1104221530
Provider Name (Legal Business Name): ACTIVE FAMILY CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/28/2014
Last Update Date: 10/28/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

501 NE HOOD AVE SUITE 205
GRESHAM OR
97030-7303
US

IV. Provider business mailing address

501 NE HOOD AVE SUITE 205
GRESHAM OR
97030-7303
US

V. Phone/Fax

Practice location:
  • Phone: 503-674-7894
  • Fax: 503-674-7899
Mailing address:
  • Phone: 503-674-7894
  • Fax: 503-674-7899

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111NP0017X
TaxonomyPediatric Chiropractor
License Number3725
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number3666
License Number StateOR

VIII. Authorized Official

Name: DR. MICHELLE K WAGGONER
Title or Position: PRESIDENT
Credential: DC
Phone: 503-674-7894