Healthcare Provider Details

I. General information

NPI: 1215104385
Provider Name (Legal Business Name): WILLAMETTE FALLS CHIROPRACTIC CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 05/08/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1609 WILLAMETTE FALLS DR
WEST LINN OR
97068-4544
US

IV. Provider business mailing address

1609 WILLAMETTE FALLS DR
WEST LINN OR
97068-4544
US

V. Phone/Fax

Practice location:
  • Phone: 503-656-1943
  • Fax: 503-650-5808
Mailing address:
  • Phone: 503-656-1943
  • Fax: 503-650-5808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111NR0400X
TaxonomyRehabilitation Chiropractor
License Number713327
License Number StateOR
# 2
Primary TaxonomyN
Taxonomy Code111NS0005X
TaxonomySports Physician Chiropractor
License Number713327
License Number StateOR

VIII. Authorized Official

Name: DR. PATRICK IABONI
Title or Position: DOCTOR
Credential: D.C., B.SC.
Phone: 503-656-1943