Healthcare Provider Details

I. General information

NPI: 1710972724
Provider Name (Legal Business Name): STEFAN MICHAEL HEROLD D.C.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2005
Last Update Date: 09/26/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1221 SE MADISON ST
PORTLAND OR
97214-3890
US

IV. Provider business mailing address

13150 SE SALMON ST
PORTLAND OR
97233-1653
US

V. Phone/Fax

Practice location:
  • Phone: 503-445-7767
  • Fax: 503-459-4221
Mailing address:
  • Phone: 503-408-6758
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number3814
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: