Healthcare Provider Details

I. General information

NPI: 1942588785
Provider Name (Legal Business Name): LIFESTREAMS CHIROPRACTIC CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2011
Last Update Date: 06/19/2020
Certification Date: 06/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

901 BRUTSCHER ST STE 210
NEWBERG OR
97132-6094
US

IV. Provider business mailing address

901 BRUTSCHER ST STE 210
NEWBERG OR
97132-6094
US

V. Phone/Fax

Practice location:
  • Phone: 503-537-2052
  • Fax: 503-538-8315
Mailing address:
  • Phone: 503-537-2052
  • Fax: 503-538-8315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number2863
License Number StateOR

VIII. Authorized Official

Name: DR. MARY ANN TACK
Title or Position: CHIROPRACTOR/OWNER
Credential: DC
Phone: 503-537-2052