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General NPI Number Information
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NPI Number | 1992243034
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Entity Type | Organization
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Legal Business Name | SOURCE HEALTH CENTER
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Dates
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Enumeration Date | 02/09/2017
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Last Update Date | 02/09/2017
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Provider Practice Location Address
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Address Line | 15455 NW GREENBRIER PKWY SUITE #150
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City | BEAVERTON
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State | OR
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Zip | 97006-7374
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Country | US
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Telephone | 503-200-5778
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Fax |
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Provider Business Mailing Address
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Address Line | 15455 NW GREENBRIER PKWY SUITE 150
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City | BEAVERTON
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State | OR
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Zip | 97006-5766
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Country | US
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Telephone | 503-200-5778
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | MICHAEL C MCCALL
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Credential | DC
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Telephone | 503-200-5778
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 111N00000X
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Taxonomy Name | Chiropractor
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License Number | 5794
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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 | 273236
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License Number State | OR
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