Healthcare Provider Details

I. General information

NPI: 1710507348
Provider Name (Legal Business Name): PREMIER CARE CHIROPRACTIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/23/2020
Last Update Date: 05/14/2024
Certification Date: 05/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1111 SE STEPHENS ST
PORTLAND OR
97214-4748
US

IV. Provider business mailing address

524 SE 14TH AVE
PORTLAND OR
97214-2428
US

V. Phone/Fax

Practice location:
  • Phone: 971-544-7058
  • Fax: 971-244-9058
Mailing address:
  • Phone: 971-544-7058
  • Fax: 971-244-9058

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number
License Number State

VIII. Authorized Official

Name: DR. TIM GALLUCCI
Title or Position: OWNER
Credential: DC
Phone: 971-544-7058