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General NPI Number Information
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NPI Number | 1942588785
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Entity Type | Organization
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Legal Business Name | LIFESTREAMS CHIROPRACTIC CENTER, LLC
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Dates
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Enumeration Date | 07/27/2011
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Last Update Date | 06/19/2020
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Provider Practice Location Address
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Address Line | 901 BRUTSCHER ST STE 210
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City | NEWBERG
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State | OR
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Zip | 97132-6094
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Country | US
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Telephone | 503-537-2052
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Fax | 503-538-8315
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Provider Business Mailing Address
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Address Line | 901 BRUTSCHER ST STE 210
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City | NEWBERG
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State | OR
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Zip | 97132-6094
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Country | US
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Telephone | 503-537-2052
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Fax | 503-538-8315
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Authorized Official
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Title or Position | CHIROPRACTOR/OWNER
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Name | DR. MARY ANN TACK
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Credential | DC
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Telephone | 503-537-2052
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | 2863
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License Number State | OR
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Taxonomy #2
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number |
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License Number State |
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