=====================================================
General NPI Number Information
=====================================================
NPI Number | 1295971810
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CITY FIT FAMILY CHIROPRACTIC CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/02/2009
-----------------------------------------------------
Last Update Date | 10/19/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 510 SW 3RD AVE STE 210
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-5010
-----------------------------------------------------
Fax | 503-248-5626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 510 SW 3RD AVE STE 210
-----------------------------------------------------
City | PORTLAND
-----------------------------------------------------
State | OR
-----------------------------------------------------
Zip | 97204-2507
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 503-224-5010
-----------------------------------------------------
Fax | 503-248-5626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. ANDREA L HERRST
-----------------------------------------------------
Credential | DC
-----------------------------------------------------
Telephone | 503-224-5010
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 111N00000X
-----------------------------------------------------
Taxonomy Name | Chiropractor
-----------------------------------------------------
License Number | 3800
-----------------------------------------------------
License Number State | OR
-----------------------------------------------------