Healthcare Provider Details

I. General information

NPI: 1467083097
Provider Name (Legal Business Name): SAMUEL SISTO-LOPEZ DC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/02/2020
Last Update Date: 05/17/2026
Certification Date: 05/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 N BOONES FERRY RD
WOODBURN OR
97071-9602
US

IV. Provider business mailing address

1034 N BOONES FERRY RD
WOODBURN OR
97071-9602
US

V. Phone/Fax

Practice location:
  • Phone: 503-603-3342
  • Fax: 503-688-9590
Mailing address:
  • Phone: 503-603-3342
  • Fax: 503-688-9590

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number6108
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: