Healthcare Provider Details

I. General information

NPI: 1235302795
Provider Name (Legal Business Name): CHIROPRACTIC LIFE CENTER PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2008
Last Update Date: 08/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12762 SE STARK ST PLAZA 125, BLDG D
PORTLAND OR
97233-1539
US

IV. Provider business mailing address

12762 SE STARK ST PLAZA 125, BLDG D
PORTLAND OR
97233-1539
US

V. Phone/Fax

Practice location:
  • Phone: 503-255-7746
  • Fax: 503-255-0818
Mailing address:
  • Phone: 503-255-7746
  • Fax: 503-255-0818

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NX0800X
TaxonomyOrthopedic Chiropractor
License Number271737
License Number StateOR

VIII. Authorized Official

Name: MARK RONALD JOHANSEN
Title or Position: OWNER
Credential: DC
Phone: 503-255-7746