Healthcare Provider Details

I. General information

NPI: 1033072251
Provider Name (Legal Business Name): FORM & FUNCTION CHIROPRACTIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2025
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 MONROE PKWY STE G
LAKE OSWEGO OR
97035-8874
US

IV. Provider business mailing address

3 MONROE PKWY STE G
LAKE OSWEGO OR
97035-8874
US

V. Phone/Fax

Practice location:
  • Phone: 503-495-3454
  • Fax:
Mailing address:
  • Phone: 503-495-3454
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State

VIII. Authorized Official

Name: JEFF DEVINE
Title or Position: PARTNER/DR
Credential: DC
Phone: 503-330-3289