Healthcare Provider Details

I. General information

NPI: 1336577311
Provider Name (Legal Business Name): NORTHWEST SPINE AND SPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/29/2013
Last Update Date: 10/27/2020
Certification Date: 10/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

850 SW BOOTH BEND RD
MCMINNVILLE OR
97128-9320
US

IV. Provider business mailing address

850 SW BOOTH BEND RD
MCMINNVILLE OR
97128-9320
US

V. Phone/Fax

Practice location:
  • Phone: 503-472-2111
  • Fax: 503-434-5886
Mailing address:
  • Phone: 503-472-2111
  • Fax: 503-434-5886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number4052
License Number StateOR

VIII. Authorized Official

Name: DR. TREVOR MARTIN STAUBER
Title or Position: OWNER
Credential: DC, MS, CCSP
Phone: 503-472-2111