Healthcare Provider Details

I. General information

NPI: 1326211673
Provider Name (Legal Business Name): MY FAMILY CHIROPRACTOR, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2008
Last Update Date: 01/20/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 NW BURNSIDE RD STE 5
GRESHAM OR
97030-3745
US

IV. Provider business mailing address

16409 SE DIVISION ST SUITE 216, PMB 285
PORTLAND OR
97236-1931
US

V. Phone/Fax

Practice location:
  • Phone: 503-666-2298
  • Fax: 503-492-2355
Mailing address:
  • Phone: 503-666-2298
  • Fax: 503-492-2355

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number3243
License Number StateOR

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1059020
Identifier TypeOTHER
Identifier StateOR
Identifier IssuerASH DOC ID
# 2
Identifier1215008834
Identifier TypeOTHER
Identifier State
Identifier IssuerINDIVIDUAL NPI

VIII. Authorized Official

Name: DR. DANIEL L DESJARDINS
Title or Position: OWNER/DOCTOR
Credential: DC
Phone: 503-666-2298