Healthcare Provider Details

I. General information

NPI: 1760206809
Provider Name (Legal Business Name): CORE MOVEMENT CHIROPRACTIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2024
Last Update Date: 12/16/2024
Certification Date: 12/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21860 WILLAMETTE DR
WEST LINN OR
97068-3256
US

IV. Provider business mailing address

21860 WILLAMETTE DR
WEST LINN OR
97068-3256
US

V. Phone/Fax

Practice location:
  • Phone: 503-650-2394
  • Fax: 503-212-3275
Mailing address:
  • Phone: 503-650-2394
  • Fax: 503-212-3275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code111NN0400X
TaxonomyNeurology Chiropractor
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code111NN1001X
TaxonomyNutrition Chiropractor
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code111NR0200X
TaxonomyRadiology Chiropractor
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number
License Number State

VIII. Authorized Official

Name: TRISTAN S MACEIRAS
Title or Position: OWNER
Credential: DC
Phone: 512-695-0971